Copyrighted Material
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CLINICAL REASONING FOR
-
MANUAL THERAPISTS
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CLINICAL REASONING FOR
MANUAL THERAPI STS Mark A. Jones
BSc (Psych), PT, Grad Dip Advan Manip Ther, l'1AppSc
Senior Lecturer, Director, Master of Musculoskeletal and Sports Physiotherapy, Physiotherapy International Coordinator, School of Health Sciences, University of South Australia, South Australia, Australia AND
Darren A. Rivett
BAppSc (Phty), Grad Dip Manip Ther, MAppSc (Manip Phty), PhD
Associate Professor, Program Convenor and Head, Discipline of Physiotherapy, School of Health Sciences, Faculty of Health, T he University of Newcastle, New South Wales, Australia Foreword by
Lance Twomey BAppSc (WAIT), BSc (Hons), PhD (w.
Aust) TTC, MADA
Vice Chanceller, Curtis University of Technology, Perth, Australia
:
UTTERWORTH E I
N
EDINBURGH
E
M
A
LONDON
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NEW YORK
OXFORD
PHILADELPHIA
Copyrighted Material
ST LOUIS
SYDNEY
TORONTO
2004
BUTTERWORTH-HEINEMANN An imprint of Elsevier Science Limited
Š 2004. Elsevier Science Limited. All rights reserved. The rights of Mark Jones and Darren Rivett to be identified as authors of the Introduction. and Chapters J and 26 have been asserted by them in accordance with the Copyright. Designs and Patents Act J 988. All other chapters are copyright of Elsevier Science Limited. No part of this publication may be reproduced. stored in a retrieval system. or transmitted in any form or by any means. electronic. mechanical. photocopying. recording or otherwise. without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency. 90 Tottenham Court Road. London W J T 4LP. Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelphia. USA: phone: (+ J) 2J5 2387869. fax: (+ 1) 215 238 2239. e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier Science homepage (http://www.elsevier.com). by selecting 'Customer Support" and then 'Obtaining Permissions'. First published 2004 ISBN 07506 39067 British Library Cataloguing in Publication Data
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A catalog record for this book is available from the Library of Congress Notice
Medical knowledge is constantly changing. Standard safety precautions must be followed. but as new research and clinical experience broaden our knowledge. changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose. the method and duration of administration. and contraindications. It is the responsibility of the practitioner. relying on experience and knowledge of the patient. to determine dosages and the best treatment for each individual patient. Neither the publbher nor the editors assume any liability for any injury and/or damage to persons or property arising from this publication. The Publisher
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Contents
List of contributors Foreword
IJ
vii
ix
I]
Lance Twomey Preface
103
123
Ankle sprain in a 14-year-old girl
Gary Hunt
xi
Introduction
o
xii
Em
135
149
Diane Lee
m
3
Thoracic pain limiting a patient's secretarial work and sport
Principles of clinical reasoning in manual therapy 1 Introduction to clinical reasoning
Headache in a mature athlete
Gwendo/en Jull
lI搂U[.j路I' a
Chronic low back and coccygeal pain
Paul Hodges
Bilateral shoulder pain in a 16-year-old long-distance swimmer
Mark A. Jones and Darren A. Rivett
161
Mary Magarey
EEl
"44;HI"
Clinical reasoning in action: case studies from expert manual therapists 25
D
Ell
D
tennis player
woman
Jenny McConnell
27
II]
194
Self-management guided by directional
Ongoing low back, leg and thorax
preference and centralization in a patient
troubles, with tennis elbow and
with low back and leg pain
headache
Robin McKenzie and Helen Clare
36
III
Chronic low back pain over 13 years
Dick Erhard and Brian Egloff
206
Craniovertebral dysfunction following a motor vehicle accident
51
215
Er/ Pettman
Ie
Unnecessary fear avoidance and
A judge's fractured radius with metal
physical incapacity in a 55-year-old
fixation following an accident
housewife
Robert Pfund in collaboration with Freddy Kaltenborn
61
Louis Gifford
D
Patellofemoral pain in a professional
Back and bilateral leg pain in a 63-year-old
David Butler
II
180
.David Magee
Mark Bookhout
D
Medial collateral ligament repair in a professional ice hockey player
A chronic case of mechanic's elbow
Toby Hall and Brian Mulligan
m 87
229
A university student with chronic facial pain
243
Mariano Rocabado
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v
CONTENTS
Ill]
Adolescent hip pain
261
'i44't.I.I'
Shirley Sahrmann
ED
A software programmer and sportsman with low back pain and sciatica
275
Theory and development
Em
312
Chronic peripartum pelvic pain
326
john van der Meij, Andry Vleeming and jan Mens
Ell
Acute on chronic low back pain
A non-musculoskeletal disorder masquerading as a musculoskeletal disorder
Improving clinical reasoning in manual
Appendix 1: Reflective diary
Index
352
Forearm pain preventing leisure activities
420
Appendix 2: Self-reflection worksheet
Peter E. Wells
Em
403
Darren A. Rivett and Mark A. jones
340
Richard Walsh and Stanley Paris
m
ED
therapy
Patricia Trott and Geoffrey Maitland
ED
379
joy Higgs
An elderly woman 'trapped within her own home' by groin pain
Educational theory and principles related to learning clinical reasoning
Tom Arild Torstensen
E1!l
377
358
Israel Zvulun
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433
421
List of contributors
J\1ark Bookhout
Joy Higgs
I''l'. MS
rhO. MHPEd. GradDipPhty, BSc
President. Physical Therapy Orthopaedic
Faculty of Health Sciences , University of Sydney,
Specialists, Inc, Minneapolis & Adjunct Associate
Sydney, Australia
Professor. Department of Physical Medicine and Rehabilitation, Michigan State University
Paul Hodges
College of Osteopathic Medicine. East Lansing.
Associate Professor. Department of Physiotherapy,
PhD. HPhly(Hons)
University of Queensland , Brisbane.
Michigan, USA
Australia David Butler
MAppS,
Gary Hunt
Director. Neuro Orthopaedic Institute and Lecturer. UniversiLy of South Australia,
Physical Therapy Program, Concord,
Adelaide, Austr<llia
Helen Clare
P'C DIY],. M/\. OCS. C['ed
Associate Professor. Franklin Pierce College New Hampshire; Senior Physical Therapist, Outpatient Physical Therapy Clinic, Cox Health
[,T, CrodDip,vlanipTher, MAppSc, DipMDeT
Systems, Springfield, Missouri. USA
fntern<ltional Director of Education, McKenzie fnstitute International. Wellington.
Mark A, Jones
Australia
BSc(Psych). PT. GradDipr\dvan,\llanipTher.
MAppSc
Brian Egloff
Senior Lecturer. Director. M aster of
MS. MP'!'
Musculoskeletal and Sports Physiotherapy,
Uniformed Services University. Bethesda
Physiotherapy International Coordinator,
MD, USA
School of Health Sciences,
Richard E, Erhard DC, P'l'
University of South Australia,
Assistant Professor, Department of Physical Therapy,
A delaide, Australia
University of Pittsburgh and Head of Physical Therapy and Chiropractic Services, University of
Gwendolen Jull
Pittsburgh Medical Centre, Pittsburgh, USA
Associate Professor, Department of Physiotherapy,
Louis Gifford
Australia
MPhty, PhD, F/\CP
University of Queensland. Brisbane . MAppSc,
SSe. Fesp
Private Practitioner, Falmouth Physiotherapy Clinic, Kestrel. Swanpool. Falmouth.
Freddy Kaltenborn
Cornwall, UK
Scheidegg. Germany
Toby Hall
Diane Lee
MSc. PostCradDipMaJlipl'hcr
Adjunct Senior Teaching Fellow, School of
PT. ProlUrhc(USA)
HSR. FCAMT
Clinical Director,
Physiotherapy, Curlin University of Technology.
Delta Orthopaedic Physiotherapy Clinic ,
Perth, Western Australia
Delta, BC. Canada
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vii
Mary Magarey
DipTechPhysioGrad. DipAdvancedManipTherapy.
Shirley Sahrmann
PT. PhD. rAPTA
Professor, Physical Therapy. Neurology.
Phil
Senior Lecturer, School of Health Sciences,
Cell Biology and Physiology, Director. Program in
University or South Australia, Adelaide, Australia
Movement Science and Associate Director. Program in Physical Therapy.
David Magee I:lPT. PhD
Washington University School of Medicine.
Professor, Department of Physical Therapy. Faculty of Rehabilitation Medicine, University of Alberta. Edmonton. AB, Canada
GeolTrey Maitland
Jenny McConnell
Tom Arild Torstensen
MBE. AlJA. FC SP. FACP. MAppSc(Hons)
Glenside, South Australia
I3AppSc. MbiorncclE
Patricia Trott
MSc(i1nal). GradlJipAdvManTher. filCP
Associate Professor, School of Health Sciences,
CNZIvl. Oi3E. FCSP. FNZSP. OipMT. DipMDT
The Mckenzie Institute International. Waikanae, New Zealand
Jan Mens
BSc(Hons). PT.
CandS cienl( Advanced MSc)
Specialist in Manipulative Therapy MNFF, NorwelY
50G5, Australia
Mosman, NSW, Australia
Robin McKenzie
St. Louis. USA
University of South Australia, Adelaide, Australia
Lance Twomey
,"ID. PhD
BAppSc(WAll'). BSc(Hons). Phll(WAusl).
'fTC'. MADA
Department of Rehabilitation Medicine, Faculty of
Vice Chancellor. Curtis University of Technology.
Medicine and Health Sciences. Erasmus MC.
Perth, Australia
Rotterdam. The Netherlands
Brian Mulligan
John van der Meij PTMT
fNZSP(Hon). iJipMT
Private Practitioner and Lecturer. Wellington, New Zealand
Stanley Paris
Pain Science and Applied Neuro Science. School for Higher Education Leiden. Leiden.
PT. PhD. FAPTA
President. University of Sl. Augustine. Florida, USA
Erl Pettman
PT. FCM"',],
Abbotsford. Be. Canada; Clinical Instructor.
Rotterdam. The Netherlands
Richard Walsh
Springs , Michigan. USA
OHSc. HSc(Med)(Hnns). DipPhys
Physiotherapy Demonstrator.
PT. OMT. MAppsc
Private Practitioner and Instructor for Orthopaedic Manuell Therapy, Physiotherapy Fetzer and Pfund. Kempten. Germany
Department of Anatomy and Structural Biology. University of Otago. Dunedin. New Zealand
Peter E. Wells
I3AppSc (Phly). GradDipManipTher.
flA.
resp.
DipTP. iv\MACP. SRP
Private Practitioner, Postgraduate Teacher.
MAppSc(ManipPhty). PhD
Associate Professor. Program Convenor and Head. Discipline of Physiotherapy. School of Health Sciences. Faculty of Health. The University or
The Physiotherapy Centre, Fulham, London. OK
Israel Zvulun
Newcastle. New South Wales. Australia
Mariano Rocabado
PT. PhD
Clinical A natomist. Spine and Joint Center.
DSc PT Program at Andrews University, Berrien
Darren A. Rive tt
The Netherlands
Andry Vleeming
Owner, McCallum Physiotherapy Clinic .
Robert Pfund
Private Practitioner Manual Therapy and Clinical Consultant Trilemma. Senior Lecturer in
BPT. MAppSe. MIPTS. MMPA
Private Practitioner and Clinical Consultant, Freelance Lecturer in Postgraduate Musculoskeletal
OP T
Full Professor. School of Dentistry.
Physiotherapy and Head of Clinical Education and
University of Chile and Director Physical Therapy
Research Unit, Rabin Medical Centre.
and Physical Medical Rehabilitation,
Golda Campus. Petah.
INTEGRAMEDICA, Santiago. Chile
Tikvah. Israel
Copyrighted Material
Foreword
To place this book's emphasis appropriately on sound
responses. This approach to the treatment of joint pain
clinical reasoning within the framework of manual
and impalrment. along with an extensive repertoire
therapy, it is necessary to appreciate the evolution of
of sophisticated manual skills. remain at the very
mcll1ual therapy as a discipline in its own right. From
heart of manual therapy.
tentative beginnings. it has advanced significantly
Manual therapists are baSically problem solvers.
since the 196()s. Initially it focussed on skill acquisition
They are approached on a daily basis by individuals
and the careful but prescriptive application or passive
seeking assistance in the management of their body
movement techniques to vertebral and peripheral
pain or their activity/participation restrictions. There
joints. The earliest courses in manual therapy con
lore. contemporary therapists need not only excellent
centrated on joint structure, biomechanics, pathology.
skills in physical assessment and treatment but also
diagnosis and physical treatment in a mechanistic
first class communication and management skills.
way. seeking simple cause and effect relationships
They need also to understand legal and ethical issues,
between a patient's symptoms and signs and their
to be aware and have knowledge of potential behav
physical treatment protocols.
ioural and psychological issues. to be prepared to
Present day manual therapy practice and education
work as part of a larger health-care Leam and to know
owes a great deal to the vision and efforts of individ
when to refer patients on and involve other disciplines
uul pioneering therapists. A considerable body of work
within the team. Manual therapists have necessarily
has gradually been developed based on relevant litera
become more holistic in their care, with a related
ture from the fields of orthodox medicine, osteopathy.
shift toward greater active management and patient
bone-setting and chiropractic. it has been further
participation.
promoted by personal contact between key interna
Clinical reasoning is both collaborative and rel1ect
tional practitioners. In addition, a substantial amount of
ive. The therapist works with the patient and with
work has been published. short courses have been
other disciplines as part of a health-care delivery model.
developed and tertiary programmes introduced.
Even manual therapists in sole practices need to be a
Manual therapy has been predominantly a highly
part of an extended multidisciplinary health network
individual and structured approach to patient exam
if a patient is to be proVided with the most appropriate
ination and treatment by (largely passive) movement.
and timely treatment and advice, pertinent to their
Historically, it has rocussed on the carerul evaluation
particular clinical condition. This approach requires
and assessment of a patient. followed by the applica
adequate time for retlection and consultation, so as to
tion of a specinc joint movement procedure and the
provide a reasoned and speci[1c response to the patient's
subsequent reassessment of the patient to evaluate
problem.
the success or otherwise of the procedure. Depending
Mark Jones and Darren Rivett have provided in
on the feedback. the therapist either continued with
this book an excellent overview of the issues central
more of the same manual procedure or else changed
to clinical reasoning in manual therapy and a wide
to another technique. Such a method is truly patient
ranging selection of case studies from many parts of
centred given that the therapist's actions and treat
the world. In addition, Joy Higgs has contributed a
ment protocol arc always guided by the patient's
key chapter on educational theory and principles
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ix
FOREWORD
relating to learning clinical reasoning. In this chapter
professionals are under closer examination than ever
readers are taken through the relevant educational
before, where patients demand both higher levels of
theory underpinning the teaching and learning (101'
communication with their therapist and involvement
mal or self·directed) of clinical reasoning. ImportanLly,
in their own treatment. where the ethical relationship
this same theory will also assist practiSing clinicians in
between therapist and patient becomes a signilicant
their patient management. As Jones and Rivett point
factor, and where the likelihood of adverse publicity
out in Chapter 1. teaching is a fund,unental compon
remains a potent force in the equation. Skilled clinical
ent or manual therapy treatment, yet manual therap
reasoning will be critical to the clinician's ability to
ists traditionally have not received formal training in
practise autonomously yet collaboratively, lo generate
educalion/learning theory and the associaled teaching
und apply new knowledge and to continue their life
slrategies. Finally, Jones and Rivett provide a chapter or
long learning.
practical suggestions on how readers can develop their
Manual therapy will only flourish as a viable discip
clinical reasoning skills. To this end, the chapter links
line through the 21st century if it learns from good
the clinical reasoning theory aod the learning theory
basic and applied research and adapts appropriately to
from the earlier chapters <md encourages the reader to
the new knowledge available. The case study approach
apply this knowledge in assessing the provided case
to knowledge acquisition has always been an import
studies and in their everyday clinical practice.
ant factor in professions as diverse as medicine, business
[n the past, manual therapy has relied as much on
and education. It is very pleasing to note the global
charismatic leadership as it has on objective evidence.
spread of the case studies in this volume and the ways
For the discipline to continue to progress in this new
in which they reinforce the basic tenets of clinical
millennium, it is essential for it to be based on strong
reasoning. This superb book takes the reader down
research, critical in its scrutiny or evidence provided
the path of knowledge and reflection to provide better
and reflective in the way in which the various treat
treatment options for all.
ment hypotheses and protocols are introduced and evaluated. This will proceed in an environment where
Copyrighted Material
Lance Twomey
Preface
This book aims to promote the development of clinical
of quick-!1x techniques. but rather a self-help book
reasoning skills, thinking or decision-making skills,
for the motivated practitioner or student seeking to
in practitioners and students of manual therapy. For
progress along the road to clinical expertise by
the purposes of this book, we consider a manual ther
improving their skills in clinical reasoning.
apist to be a health-care practitioner who regularly
The core of this book is the 23 detailed case reports
deals with the problems that are attributed to disorders
in Section 2, which have been contributed by renowned
of the neuromuscuJoskeletal system. The original pro
and expert manual therapists from all over the world.
fessional training of the manual therapist. whether it
We would like to express our sincere gratitude to the
be in physiotherapy, chiropractic, osteopathy, medi
case contributors, first for their enthusiasm for this
cine or another profession. is not important because
innovative project and, secondly and especially. lor
the clinical reasoning process is universal. As the term
their patience as the individual cases were developed
implies, manual therapists work to a large degree
and the associated clinical reasoning painstakingly
with their hands. although this should not be seen to
made explicit. Special thanks are also due to Professor
limit the role of the mallual therapist to techniques
Joy Higgs for her important and insightful contribu
such as manipulation. mobilization or soft tissue pro
tion with Chapter 2.5.
cedures. or to suggest that the patient's role is merely that of a passive reCipient of the therapist's healing
Finally, we wish to acknowledge the unwavering encouragement and support of Helen and Jannine.
hands. Indeed, manual therapists utilize a broad range
We hope that this book will be of value to manual
of hands-off physical and communicative (e.g. teach
therapy clinicians. students and teachers and will
ing) management approaches, and all manual ther
help to promote the role of clinical reasoning as the
apy practice requires active patient participation and
common loundation of all forms of manual therapy
collaborative decision making. Manual therapists are
practice.
now more than ever required to account for their clin ical decisions against a background of competing
M. A. Jones
demands such as evidence-based practice. funding
Adelaide, Australia, 2004
limitations, legal and ethical issues, and the informa
D. A. Rivett
tion explosion in health care; this all makes an
Newcastle, Australia, 2004
increaSingly difficult task. As such, this is not a textbook
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xi
Introduction
Manual therapy expertise is multidimensional. incorp
have very good logical thinking skills while lacking
orating a combination of innate and learned charac
the creative and lateral thinking abilities required to
teristics including intellectual aptitude. personality
advance their profession.
(e.g. curiosity. empathy. humility). knowledge organi
Closely associated with the content that is taught
zation. plus communication. manual and thinking
in our manual therapy courses are the beliefs we fos
skills. Experts are often considered to be 'good thinkers',
ter. For example. many students and beginning prac
but traditionally our academic and continuing educa
titioners of manual therapy will adopt an allegiance
tion manual therapy programmes have given little
to a particular clinical approach. This in itself is prob
formal attention specil1caUy to assessing and teaching
ably healthy. as a student who has acquired a system
thinking skills. It is common for people to question the
atic approach to assessment and management is well
need to address thinking skills formally. since all of us
equipped to integrate additional philosophies and tech
interpret. judge relevance. hypothesize. extrClpolate.
niques. providing the necessary open mindedness is
test hypotheses, prioritize, weigh evidence, draw con
there at the outset. Unfortunately. however. political
clusions. devise Clrguments. plan. monitor the effects of
divisions between different manual therapy approaches .
our efforts. and engage in numerous other activities
and even within some approaches. have held many
that fall in the domClin of clinical reasoning anyway.
clinicians back from learning anything more than what
despite possibly never having received focussed instruc
their own approach offers. Rel1ection is not openly
tion in thinking processes. However, this is not to
promoted and hence students and clinicians histor
say that we do these things well in all circumstances
iC(:llly have not been encouraged to explore and chal
or that we Clre unable to learn to do them better.
lenge their own beliefs.
It is often assumed that the thinking process will
Ret1ective scepticism means not taking for granted
students/clinicians Clcquire the necessary
any position. policy or justil1cation simply because it
knowledge base and practise applying this knowledge
h(:ls been presented by a source of authority. Many
improve
CIS
in clinical situations. While this can be true and our
of our earlier beliefs. rules or strategies in manual
manual therapy programmes have obviously produced
therapy were formulated on the basis of empirical
many good thinkers. many poor thinkers have also
observations in the clinic and attempts to fit existing
come out of this traditional educational system. Weal<er
biomedic(:ll theory to those clinical observations. In
students and clinicians ol'ten lack key aspects of skilled
contrast. with the incre(:lsed focus on evidence-based
clinical reasoning . which limits their ability to acquire
practice. there (:lre growing pressures from both
knowledge through their education. or they acquire
within and outside the profession for greater account
the knowledge but have great diffIculty in applying
ability (:lnd substantiation of clinical effIcacy. This.
this knowledge in a clinical context. Stronger students
combined with the push ror manual therapists to
and clinicians seem to possess good thinking skills
adopt the broader biopsychosocial model of health
already. so when equipped with further knowledge
and disability. has contributed to the current st(:lte of
they tend to excel. Or do they? Do we take our strong
manual ther(:lpy education. Contemporary manual
students and clinicians as far as they are capable?
therapy education. while acknowledging its roots.
And does this apply to you? Often an individual may
has moved forward to a biopsychosocial. reasoning
xii
Copyrighted Material
INTRODUCTION
•
and evidence-based system. Importantly, this evidence
of patient cases contributed by expert manual thera
includes both propositional knowledge derived from
pists from around the globe. Experts were selected
research and well-tested. practice-generated profes
based on their status in the manual therapy world, as
sional craft knowledge.
established through their clinical excellence. research.
The inl1uences of evidence-based practice. bio
publications and teaching prol1le. An attempt was
psychosocial models of health. and clinical reasoning
made to have different 'approaches' of manual ther
theory have provided an exciting btidge between dif
apy represented, as well as a wide array of patient
ferent approaches to manual therapy. The clinical
problems from the more straightforward to the more
1.
complex. Case contributors were simply requested to
reasoning process itself. as outlined in Chapter
should be fundamental to all approaches of manual
submit a real patient case, including their full exam
therapy. Skilled clinical reasoning is essential for the
ination and management through to the point of
application of both research-based and experience
closure. Following that, clinical reasoning questions
based evidence. As such. if all students and clinicians
were devised by the editors to extract each clinician's
could learn their respective approaches to manual
evolving thoughts throughout their own case. Our
therapy with specilk atlention to the cognitive skills
clinical reasoning commentary was then added with
of reasoning. including being reflectively critical of
the aim of highlighting examples of clinical reasoning
the assumptions thai underlie their own beliefs and
theory in practice. We have not attempted to critique
open minded to modification of their current views.
the clinicians' reasoning: rather we merely hope to
then the diversity within manual therapy could better
assist readers' understanding of clinical reasoning
contribute to advancement in the assessment and
theory by pointing out specilk examples as Lhey
management of patients' problems.
emerged through the unfolding cases reports.
While clinical reasoning has always been implic
To maximize what can be gained from reviewing
itly taught in manual therapy education. it has only
these cases. our suggestion is to read through the case
1990s that clinical reasoning theory
and reasoning questions and attempt to formulate your
been since the
and learning activities have been more explicitly inte
own answer before reading the clinician's answer.
grated into manual therapy curricula. The text by
Most questions relate to hypotheses formulated on
(2000: Clinical Reasoning in the
the basis of the information presented to that point.
Health Professions). now in its second edition. has pro
Occasionally. clinicians are asked to extrapolate on
Higgs and Jones
vided health science educators with a rich resource of
their own philosophy or specific assessment and man
clinical reasoning theory linked to education theory.
agement procedures used. Where the answers differ
However. what has been lacking is a practical resource
from what you might have answered, take the oppor
for manual therapy clinicians and students who wish to
tunity to stop and reOect on the basis for your opinion.
reOect and improve on their own clinical reasoning.
Reasoning is not an exact science and the analysis of
Clinical Reasoning for ManualTherapists has been writ
what are often complex, multifactorial patient pre
ten specifically for that purpose. This text will also pro
sentations cannot be reduced to simple correct versus
vide manual therapy educators \vith a valuable bank of
incorrect interpretations. For these cases to achieve
patient cases that can be utilized in learning activities
their full educational potential. readers must attempt
designed to facilitate students' clinical reasoning.
to reason through each case themselves and then openly reOect on and critique the reasoning expressed, the evidence substantiating judgments made and,
Outline of the book
importantly, your own reasoning. regardless of whether you agree or disagree with that put forward by the
The book commences "vith a theory chapter (Chapter 1)
expert clinician.
on clinical reasoning covering both basic and con
In order to achieve our aim of providing a resource
temporary clinical reasoning theory. It is hoped that
that will assist students and clinicians to improve their
readers will read this chapter prior to progressing to
clinical reasoning, it was essential to include a chap
the case studies. as the clinical reasoning questions
ter on educational theory and principles related to
posed to the case contributors and the clinical reason
learning clinical reasoning. Chapter 25 by Joy Higgs
ing commentary that follows their answers draw on
provides this background. While the relevance of this
this theory. Section 2 (Chapters 2-24) is a compilation
chapter to manual therapy educators (including
Copyrighted Material
•
INTRODUCTION
clinical supervisors) is obvious, the theory and prin
alternative but readily accessible resources. There are
ciples discussed are equally essential to practising clin
learning activities that can be undertaken alone by
icians. Teaching is a central component of manual
the individual clinician, activities that involve a col
therapy practice, and patient learning (e.g. altered
league or mentor and ones that can be undertaken
patient understanding/beliefs. feelings and health
within the smaU group situation. The continual process
behaviours) is a primary outcome sought from collab
of learning clinical reasoning in both real life and simu
orative reasoning. As very few manual therapists
lated clinical experiences is discussed in depth and
have received any formal schooling in education or
made practical. Examples of high-technology learn
learning theory, this chapter is vital to be able to pro
ing activities (e.g. commercially available interactive
mote effectively change in your students. your patients
computer programmes) and low-technology learning
and yourselr.
activities (e.g. the use of a rellective diary) are given
Lastly, Chapter 2 () has been written to assist those
and their 'pros and cons' debated. Indeed. there is a
clinicians and students who wish to continue to
learning experience suitable for every therapist or stu
improve their clinical reasoning and for educators of
dent. no matter what their stage of education. learn
manual therapy who desire to enhance the develop
ing style or available resources.
ment of such skills in their students. We view clinical
We expect that this book will be of benefit for stu
reasoning as an essential competency in manual ther
dents studying manual therapy and lor the v arious
apy and, like any competency. skill is only acquired
types of clinician working in this field and will provide
through continued practice, rellection. feedback and
a valuable resource for instructors. To make the most
then further practice. In this chapter. following a dis
of the book. the reader should strive to keep in mind
cussion on the development of clinical expertise and
that the learning of clinical reasoning and the devel
common clinical reasoning errors. we provide a var
opment of related thinking skills requires the individ
iety of suggestions for learning activities that can be
ual to participate actively in their learning and at all
used to further practice and develop your clinical
times maintain an open but sceptical mind during
reasoning skills (or that of students). Some of these
this process. Consequently. the acquisition of clinical
activities involve using the patient cases found in
reasoning skill. and hence expertise in manual ther
Section 2. as previously discussed. while others utilize
apy. is in your hands.
• Reference Higgs. J. and Jones.
M. (eds.) (2000). Clinical Reasoning in the 2nd edn. Oxford: Butterworth-Heinemann.
Health Professions.
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Principles of clinical reasoning in manual therapy II Introduction to clinical reasoning Mark A. Jones
3
and Darren A. Rivell
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1
Introduction to clinical reasoning •
Mark A. Jones and Darren A. Rivett
Maoual therapists work with a multitude of problem presentations in a variety of clinical practice environ ments (e.g. outpatient clinics, private practices, hos pital or outpatient-based rehabilitation and pain unit teams. sports settings, home care and industrial work sites). The clinical presentations they encounter are, therefore, varied, ranging from discrete well-defined problems amenable to technical solutions to complex, multifactorial problems with uniqueness to the indi vidual that defy the technical rationality of simply applying a 'proven' set course of management. Schon (1987, p. 3) characterizes this continuum of profes sional practice as existing between the 'high, hard ground of technical rationality' and 'the swampy low land' where 'messy, confusing problems defy tedmical solution'. As will be evident in the case studies of this book, manual therapists must. therefore, be able to practise at both ends of the continuum. Manual ther apists must have a good biomedical and professional knowledge base as well as advanced technical skills to solve problems of a discrete, well-defined nature. However. to understand and manage successrully the 'swampy lowland' of complex patient problems requires a rich blend of biomedical, psychosocial, pro fessional craft and personal knowledge, together with diagnostic, teaching, negotiating, listening and coun seJJing skills. Contemporary manual therapists must have a high level of knowledge and skills across a comprehensive range of competencies, including assess ment, management, communication, documentation, and professional. legal and ethical comportment. Effective performance within and across these competencies requires a broad perspective of what
constitutes health and disability and equally broad skills in both diagnostic and non-diagnostic clinical reasoning. In this chapter we present a contemporary per spective on clinical reasoning in manual therapy. Clinical reasoning is portrayed as being multidimen sional. It is hypothesis oriented. collaborative and rel1ec tive. Skilled clinical reasoning contributes to therapiSts' learning and to the transformation of existing perspec tives. A framework that describes the organization of knowledge by manual therapists is proposed together with a model of health and rusabiUty/recovery. We consider these will be helpful in promoting a broader perspective on patients' problems and will serve as a reference for exploring the reasoning of individual therapists.
What is clinical reasoning? Clinical reasoning has been defined as a process in which the therapist, interacting with the patient and significant others (e.g. family and other health-care team members), structures meaning, goals and health management strategies based on clinical data, client choices and professional judgment and knowledge (Higgs and Jones, 2000). It is this thinking and decision malcing associated with clinical practice that enables therapists to take the best-judged action for individual patients. In this sense, clinical reasoning is the means to 'wise' action (Cervero, 1988; Harris, 1993). Figure 1.1 depicts the integrated, patient-centred model of collaborative reasoning we hope to promote.
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3
PRINCIPLES OF CLINICAL REASONING IN MANUAL THERAPY
THERAPIST INFORMATION PERCEPTION
more informalion needed
DATA COLLECTION •
Subjective interview
•
Physical examination explanation more information volunteered
•
education
•
trealment
•
strategies
I+------+---.J . home exercises
Fig. 1.1
•
participates
-learns •
follows
Patient-centred model of clinical reasoning (Edwards and Jones. unpublished assignment).
In this model. clinical reasoning is seen as a process of renective enquiry comprising three core elements cognition. metacognition and knowledge--carried out in a collaborative framework with the relevant parties (e.g. the patient. carers, other health-care providers, the workplace and funding bodies) (Edwards and Jones,
1996: Jones et al.. 2000). Numerous variables innuence the success of this collaborative
therapist-patient reasoning process.
including:
Understanding both the 'problem' and the 'person' determine management To understand and manage patients and their prob lems successfully, manual therapists must consider not only the physical diagnostic possibilities (including the structures involved and the associated pathobiology) but also the full range of factors that can contribute to a person's health. particularly the effects these
• attributes of the therapist (e.g. breadth, depth and
problems may have on patients' lives. and the under
organization of knowledge , familiarity and experi
standing patients (and significant others) have of
ence with the type of case being managed. reason
these problems and their management. Skilled thera
ing proficiency, communication and teachn i g
pists do this through a process of enquiry/interview, physical and environmental examination and ongoing
and professional craft skills) • attributes of the patient (e.g. needs, beliefs/attitudes
management, where clues gleaned from the patient's
and individual physical and psychosocial circum
presentation elicit hypotheses regarding the person
stances, including their capacity and willingness
and their presenting problems (Jones, 1992: Jones
to participate in shared decision making and man
et al.. 2000; Rivett and Higgs. 1997). Except in very straightforward presentations, when expert clinicians
agement) • attributes of the environment (e.g. resources. time.
are quickly able to recognize the problem and the solu
funding, and any externally imposed professional
tion. these hypotheses then serve to guide further
or regulatory requirements).
enquiries, assessment and eventually management.
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In attempting to understand patients and their prob lems, manual therapists must be able to think along multiple lines and often think on different levels at the same time.
The clinical reasoning process is hypothesis oriented in that patient data prompt the therapist's consider ation of compeling interpretations. which are, in turn. claril'icd and lesled lhrough further data collec tion and reassessmenl of management interventions (Fig. 1.1). Although many therapists do not realise it, they are generating hypotheses from the opening moments of a patient encounter (Doody and McAteer, 2002; Rivett and Higgs, 1997). That is, initial cues, such as a referral, case notes, observations of the patient in the waiting room, and opening introductions and enquiries with the patient. will evoke a range of initial impressions. While typically not thought of as such, they can be considered hypotheses. These initial hypotheses may be physical. psychological or socially related, with or without a diagnostic implication. They are usually somewhat broad and serve to delin eate the boundaries in which the assessment will proceed . All therapists have an element of routine to their examination. Individual therapists will have identi fied, through experience, the categories of informa tion which they have found to be particularly useful for understanding and managing patients' problems. For example: •
• •
• • • •
•
personal profile including work, family and social circumstances site, behaviour and history of symptoms psychological/cognitive/affective status, expect ations and goals general medical status: clinical yellow and red flag screening occupational blue flag screening socio-occupational black flag screening functional and structure-specific tests of the cardio vascular. respiratory and neuromusculoskeletal systems ergonomic and environmental analysis, etc.
While a degree of routine commonly exists. the spe cific enquiries and tests should be tailored to each patient's unique presentation.
Narrative reasoning
Through a process of enquiry. examination and rel1ect ive management. the therapist attempts to understand the patient's problem, while at the same time trying to understand the patient's personal story/narrative or the context of the problem beyond the mere chronological sequence of events. Understanding the context. also called 'narrative reasoning' (Christensen et aI., 2002; Edwards, 2001; Fleming and Mattingly. 2000; Jones et al., 2000, 2002). requires attempting to understand the patient as a person. including their perspective of the problem. their experiences (e.g. understanding, beliefs, desires. motivations, emotions), the basis of their perspectives and how the problem is affecting their life (i.e. their pain or illness experience). This dimension of reasoning and understanding requires more than a good biomedical knowledge base and technical skills. Successful narrative reasoning, aimed at understand ing the person. requires a good organization of bio psychosocial Imowledge and the communication skills in order to apply that knowledge successfully. Narrative reasoning also necessitates a level of openness on the part of the therapist. both v\lith respect to accepting the patient's story and with awareness of their own per sonal perspectives, and even biases. on matters such as chronic disability and pain. compensation cases and cultural issues. Therapists' personal perspectives on such issues will influence their approach (e.g. attitudes. expectations, communication/relationship) to their patients and their problems, with rel1ection required to recognize, and where necessary alter. inaccurate or unhelpful perspectives. Patients' understanding/beliefs, attitudes. emotions and expectations represent what Mezirow (1990, 1991) has called their 'meaning perspective' (syn onymous with 'frame of reference'). Understanding a patient's meaning perspective is the basis of narrative reasoning. An individual's meaning perspective is acquired and evolves from a combination of personal, societal and cultural experiences. where conscious and unconscious interpretations. attributions and emotions coalesce to make up their views and feel ings. Mezirow (1991. p. xiii) states, ' ... that it is not sO much what happens to people but how they interpret and explain what happens to them that determines their actions. their hopes. their contentment and emotional well-being, and their performance'. In this sense. patients' meaning perspectives create sets of habitual expectations that serve as a (usually
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PRINCIPLES OF CLINICAL REASONING IN MANUAL THERAPY
tacit) belief system for interpreting and evaluating experiences. In the context of manual therapy, patients' meaning perspectives become f1lters through which their perceptions and comprehension of any new experience must pass. Therefore, if a patient's mean ing perspective is distorted-judged by the therapist to be counterproductive to recovery-such as 'pain equals further damage' or 'the damage I have is per manent and I will not improve further', then their perception (or lack of ) and interpretation of new experiences (including the therapist's assessment and management) will also be distorted. In fact , distorted meaning perspectives or beliefs are typically more rigid and less amenable to change (Mezirow, 1991). Analogous to attempting to identify underlying physical contributing factors to patients' symptomatic structures, it is necessary for manual therapists to delve into the basis of patients' meaning perspectives (i.e. their understanding. emotions. beliefs and attri bu tions) in order to understand these perspectives. Patients' meaning perspectives are re!1ected in their 'story' or the context in which those views were shaped. While sometimes the information comes forward spon taneously. therapists must be able to listen for and enquire about (i.e. screen) patients' meaning perspec tives and their basis, so as to identify patterns of dis tortion that require attention. While some patients' perspectives will fit recognizable patterns, others will be unique and defy some universal truth of 'normal' or 'unhelpful'. In other words. narrative reasoning decisions cannot be reduced to a correct or incorrect empirical judgment. Rather. therapists' hypotheses regarding patients' meaning perspectives can only be validated through therapist-patient consensus, or what has been labelled communicative (as opposed to pro cedural) management. As it is beyond the scope of this chapter to cover the full range of psychosocial issues for which therapists should screen, readers are referred to the texts by Butler (2000), Main and Spanswick (2000a), Strong et al. (2002) and Gifford (2000) for more thorough discussions of psychosocial screening.
Diagnostic versus narrative reasoning A distinction can then be made between understanding and managing the problem to effect change (requiring biomedically driven cause and effect thinking and action: diagnostic reasoning and procedural management) versus understanding and interacting with the person to effect change (requiring biopsychosocially driven
narrative reasoning and communicative management). In reality, a comprehensive diagnosis should encompass what is learned from both the diagnostic reasoning regarding the physical problem and the narrative rea soning regarding the person. All forms of reasoning and management should be carried out collaboratively. These seemingly different foci of thinking and management (directed to the problem and directed to the person) are not mutually exclusive. as the under standing of one enhances the therapist's understanding of the other. For example, attempting to understand and then attempting to facilitate change in the person (e.g. beliefs. emotions and health behaviours) is aided through a greater insight into the problem. The extent and nature of patients' activity and participa tion restrictions (World Health Organization. 2001; i.e. physical disabilities and associated handicaps) and impairments forms part of the context in which their psychosocial status must be viewed. A degree of stress and feelings of frustration, anger and even depression may be quite 'normal' in the presence of marked restrictions in activity and participation. Maladaptive thoughts and feelings can also coexist with physical impairment without necessarily driving or being the underlying source of those restrictions. Similarly, however. understanding a problem and then attempting to facilitate change (e.g. activity restrictions and physical impairments) is aided through greater insight about the person. Patients' feelings. beliefs and health behaviours may be contributory to the recovery or detrimental (i.e. counterproductive to their recovery), and judgments regarding these aspects of the patient require effective interpersonal and enquiry skills. including biopsychosociaJ knowledge of what to look for, management strategies and referral pathways. Just as activity restrictions (e.g. dHficulty climbing stairs) must be considered with respect to any physical impairments that may be present (e.g. mobility and motor control), the patient's feelings. beliefs and health behaviours must also be considered \\Tith respect to their experiences and related consequences, which may have contributed to shaping their views and behaviours (Butier. 2000; Gifford, 1998a. 2001. 2002; Main and Booker, 2000; Main and Parker, 2000; Watson, 2000; Watson and Kendall. 2000). Success in promoting change in both the problem and the person necessitates fostering the patient's insight into their own feelings. beliefs and behaviours, including their basis and where change would be beneficial. Reaching this level of mutual understanding requires collaborative
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1 INTRODUCTION TO CLINICAL REASONING
reasoning or shared decision making between patient
par ticular, manual therapy intervention (procedural
and therapist. as well as therapist skills in communi
and communicative) serves as another test of the
cating and teaching. Similarly. as the physical and the
hypotheses formed, consensus made and subsequent
psychological are closely linked. both procedural man
chosen course of action. Re-assessment either provides
agement, consisting of physically oriented active and
support for these decisions or signals the need for modi
passive interventions. and communicative manage
fication (of hypotheses). further perspective discus
ment. consisting of education, advice and consensual
sion (Le. revisit the previous consensus reached) or
perspective re-evaluation,
further data collection (e.g. additional clinical exam
will affect the other.
For the purposes of this book, hypothesis-oriented
ination or referral for other health professional consult
reasoning is defmed very broadly as the reflective
ation). At the micro level. therapists are constantly
process of attending to patient information by con
attending to patient responses (e.g. listening. clarify
sciously attempting to relate different features either to
ing, obserVing, feeling) and using these to build their
recognizable clinical patterns or to new, previously
understanding and guide clinical decisions to modify
unrecognized patterns unique to the individual. Reflect
and improve their interventions. At the macro level,
ive attention to different patient cues and the subse
whole treatment sessions or even multiple treatments
quent critical search for supporting/conflrming cues is
will be used to test the therapist's and patient's under
put fonvard as essential to
standing and shared management decisions.
aU reasoning processes,
including attempting to understand the person and
Although this account of management/re-assess
attempting to understand the problem. This cognitive
ment is described within the hypothesis-oriented
activity of interpreting patient cues with respect to
approach,
information already obtained represents a form of
throughout management cannot be simply reduced
in
reality
the
reasoning
undertal<en
hypothesis testing and includes attending to and
to an empirical-analytical approach. The various forms
searching for both supporting and negating evidence.
of management (e.g. specific procedures, therapist
As referred to above. while some interpretations can be
patient communication during management and
empirica.lly validated. others will only be validated
teaching) can be carried out both in an instrumental
through therapist-patient consensus of the situation
cause and effect approach. where specified. measur
(e.g. patients' beliefs/perspectives and the basis on
able outcomes are sought. and in a communicative
which they were formed). As the patient's story unfolds,
approach, where absolute truths are not available
the cumulative information obtained is interpreted ['or
and validation is achieved through therapist-patient
its lit with the broader evidence from available research
common understanding and consensus.
and the particular patient's presentation. including pre
Cognition, featured in the left-hand box in Figure
viously obtained data, hypotheses considered and con
1.1, is purposeful thought. The cognition underlying
sensus reached. Even routine enquiries. tests and
clinical reasoning includes the perception of relevant
spontaneous information offered by the patient will be
information, specific data interpretations or induc
interpreted in the context of initial impressions or
tions; drawing inferences and generating hypotheses
hypotheses. In this way. the manual therapist acquires
(deductions) from the synthesis of multiple cues; and
an evolving understanding of the patient and the
testing for competing hypotheses. Higher-order cogni
patient's problem(s). Initial impressions ,.viII be modified
tion
and new ones considered. The therapist's hypothesis
of one's own thinking and understanding is discussed
(metacognition) in the ['orm of reflective appraisal
oriented diagnostic and narrative reasoning continues
below under Reasoning as a reflective process.
until sufficient understanding (of the person and the problem) is reached by both therapist and patient to enable joint determination of a plan of management.
Pattern recognition Pattern recognition is a characteristic of all mature thought. In .both everyday life and in the realm of
The role of re-assessment in reasoning
manual therapy, knowledge is stored in our memory in chunks or patterns that facilitate more efficient
The clinical reasoning of the therapist and patient
communication and thinking
continues throughout the ongoing management. In
Ericsson and Smith, 1991: Hayes and Adams. 2000;
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(Anderson, 1990;
PRINCIPLES OF CLINICAL REASONING IN MANUAL THERAPY
Newell and Simon. 1972: Rumelhart and Ortony. 1977; Shon. 1983). These patterns form prototypes of frequently experienced situations that individuals use to recognize and interpret other situations. In manual therapy. patterns exist not only in classic diagnostic syndromes and associated management strategies but also in the pathobiological mechanisms associated with those syndromes and the multitude of environmental. physical. psychological (cognitive and affective). social. behavioural and cultural factors that contribute to the development and maintenance of patients' problems. For example. it is possible to recognize the typical clinical features of a shoulder subacromial impingement problem. as well as differ ent patterns of common anatomical. biomechanical. motor patterni.ng and technique/equipment factors that can contribute to this disorder. Importantly. patients can have the same pathology but quite differ ent contributing factors. necessitating different and very individualized management if success is to be realised and maintained. Manual therapists also must be able to recognize patterns of biomedical factors that contraindicate manual therapy. such as clinical red jlags (i.e. serious organic pathology) (Roberts. 2000) and biopsychosocial personal. family and work-related factors (yellow. blue and black nags. respectively) that may predispose to chronic pain. prolonged loss of work and serve as potential obstacles to recovery (Kendall et a1.. 1997: Main and Burton. 2000; Main et a1.. 2000). These are further discussed below under Prognosis. Pattern recognition is required to generate hypoth eses and hypothesis testing provides the means by which those patterns are reflOed. proved reliable and new patterns are learned (Barrows and Feltovich. 1987). While expert therapists are able to function largely on pattern recognition. novices who lack suffi cient knowledge and experience to recognize clinical patterns will rely on the slower hypothesis testing approach to work through a problem. However. when confronted with a complex. unfamiliar problem. the expert. like the novice. will rely more on the hypothesis oriented method of clinical reasoning (Barrows and Feltovich. 1987: Patel and Groen. 1991). Narrative reasoning and communicative management are still required to reveal and act on patients' meaning per spectives. regardless of whether pattern recognition or hypothesis testing dominates. Despite pattern recognition being a mode of thinking used by experts in all professions (Schon. 1983). it also represents perhaps the greatest source of errors in our thinking.
Related and other common errors of clinical reason ing are discussed in Chapter 26.
Reasoning as a collaborative process Successful management of patients' problems requires more than just good diagnostic and manual skills: manual therapists must also be good teachers. In fact. while a certain percentage of patients' problems can be forever resolved through the sole intervention of the therapist's manual techniques. often lasting changes are only effected by understanding the par ticular determinants of health and behaviour operat ing and by negotiating changes in the patients' understanding. beliefs/attitudes and behaviours. For example. patients' understanding of their problems has been shown to impact on their self-efficacy. levels of pain tolerance. disability. time off work and even tual outcome (Borkan et al.. 1991: Feuerstein and Beattie. 1995; Lackner et aI.. 1996: Main and Booker. 2000; Main et al. . 2000; Malt and Olafson. 1995: Strong. 1995: Watson. 20(0). Manual therapists have generally only learned through personal experience the ski Us of psychosocial assessment and management (e.g. listening. commu nicating. negotiating. counselling and motivating) needed to effect positive changes in their patients' health understandings. beliefs and behaviours. While such skills are increasingly being made more explicit in manual therapy curricula. in general these aspects have not historically been given the same attention in terms of theory and application as has clinical reasoning in physical diagnosis and management. Consequently. biopsychosocial knowledge and inter personal skills are often tacit and underdeveloped in some therapists. The collaborative nature of the reasoning process is highlighted by the arrows interconnecting the centre and the boxes on the right in Figure 1.1. Whereas the centre boxes feature the therapist's reasoning. the boxes on the right depict the patient's thoughts and understanding. Thus. patients begin their encounter with a manual therapist with their own ideas of and feelings about the nature of their problem(s) and the management they need. as shaped by personal experience and advice from medical practitioners. family and friends. Through a process of evaluating patients' understandings. beliefs and feelings (meaning perspectives). and through the use of explanation.
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reassurance and shared decision making. the therap ist can involve the patient in developing an evolving understanding of the problem and its management. Beliefs and feelings that are counterproductive to a patient's management and recovery. such as exces sive fear of movement or pain. can contribute to phys ical deconditioning. poor compliance vvith self management. poor self-efficacy and ultimately a poor outcome (Hill. 1998: Main and Booker. 2000). Patients who have been given an opportunity to share in the decision making have been shown to take greater responsibility for their own management and have a greater likelihood of achieving better outcomes (Bucklew et aI., 1994: Burkhardt et al.. 1994; Lorig et al .. 1999: Niestadt, 1995: Shendell-Falil<. 1990), Patient learning is a primary outcome sought from collaborative reasoning (Jones et at.. 2000). Rather than being passive recipients of health care, patients construct a new understanding or meaning perspec tive. one in which they are actively involved in man agement decisions and share in the responsibility for their health care. While tbis discussion has focussed on the collabora tive reasoning between therapist and patient. a Similar collaborative process should exist between the therapist and carers. as well as with other members of the health-care team and funding bodies. This broader role of the manual therapist in the local and global health care community as an interactional professional is dis cussed more extensively in Higgs and Hunt (1999a.b).
manual therapists. neurological physiotherapists and domiciliary care physiotherapists skilfully employed such reasoning. It occurs on different levels from the provision of simple advice to motor retraining and explanation directed to changing patients' meaning perspectives. In all situations. the therapist must make judgments concerning the level and amount of teach ing that is appropriate for an individual patient and the mode of delivery that is most suitable and likely to be accepted by the patient. For example. expert therap ists will often strategically use 'stories' regarding other patients as a means of building rapport. educating and communicating prognostic outcomes (Edwards. 2001). Such real-life scenarios bring credibility to the advice or explanation that they are used to support and can be strategically employed by therapists to strengthen their message. Learning theory is discussed in Chapter 25. where transformative learning (described by Mezirow (1990) as perspective transformation) is defined as the con struction of meaning (Le. knowledge) from experi ence. The individual's revised understanding will then guide their future perspectives (understanding. appreciation and behaviour). Facilitating this level of learning necessitates the learner (patient or therapist) engaging in critical rel1ection. Presuppositions of current beliefs are re-examined. opening the way for new. revised perspectives. Both therapists and patients at times need to renect critically on the basis of their beliefs. so that distortions in meaning per spectives (beliefs) may be identified and corrected.
Reasoning as a reflective process
Learning from reflection
Learning should be seen as a central outcome of clin ical reasoning for both therapist and patient. While all therapists would hopefully see themselves as both teachers and learners. learning theory has traditionally not been a core area of study for manual therapists. apart perhaps from the formal attention to learning theory that accompanies concepts of motor learning. However. given the importance most therapists would acknowledge teaching has in their patient manage ment (Jensen et al.. 1999. 2000: Sluijs, 1991). this is an obvioLls deficiency.
Teaching Teaching is a ubiqUitous activity requiring its own focus of reasoning. Edwards (20CH) found that expert
To learn from your own cUnical experiences and grow as a therapist requires reasoning that is open minded and rel1ective, Reflection is an act of cognition that can be used in different ways, In a simplest form. these thoughtful activities represent reflective thought. for example. when the significance of a piece of informa tion is actively considered or when different and sometimes connicting findings are assessed. However. rel1ective thinking at a higher level. metacognition. involves thinking about your thinking and the factors that limit it. Metacognition is a well-recognized char acteristic of expertise (Alexander and Judy, 1988: Biggs. 1986). Metacognitive reflections may be directed at any of the following: •
the information available (e.g. awareness of the quality and relevance of information obtained)
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PRINCIPLES OF CLINICAL REASONING IN MANUAL THERAPY
the reasoning process (e.g. awareness of specific strategies required to understand the person and the problem and achieve the desired goals) • the hypotheses rormed and decisions reached (e.g. research and experience-based evidence for assess ment and management decisions) • the organization of knowledge (e.g. awareness of one's own knowledge base, personal perspectives. biases and any limitations).
•
Reflection can occur in what Schon (1983. 1987) has called rej1ection-in-action, where you literally pause during a patient encounter and consider any of these issues , or in hindsight as a rej1ection-about action. Too often a patient's status changes. for the better or the worse. without the therapist having or taking the time to reflect on the change. In a busy practice. improvement is a godsend as it means the treatment can be repeated with little deliberation. A lack of improvement typically leads to a change in treatment with some consideration of the options available. but often without any serious reflection on prior judgments made and the underlying reasoning that led to the current lack of improvement. The reflective thinker is sceptical. always question ing the reliability. validity and overall relevance of findings and interpretations. and ever prepared to accept that their own knowledge base may be inad equate. Brookfield (1987.2000) cites this trait as a key component of all critical thinking. not just clinical reasoning. He stresses the importance of being will ing and able to identiry and challenge the assump tions that underlie beliefs and actions. Reflecting on the basis of one's preconceptions may include con Sidering such things as what information is relevant: what constitutes a particular diagnostic, psychosocial or behavioural pattern: what evidence (research valid ated or experience based) exists to support judgments and inter ventions: and the appropriateness or the model or health and recovery followed.
Awareness of new perspectives Associated with becoming aware of the assumptions that underlie a belier is the recognition of the context from which those assumptions arose. That is. many of our beliefs are formed from cultural. historical or specific philosophical frames or reference: when these rrames of reference are appreciated. a deeper
understanding of the belier itself and a more informed position from which to evaluate the belief can be achieved. A healthy reflective scepticism, where a par ticular philosophy, position or justification is not taken for granted simply because it has been presented by a source or authority or been unchanged for a long time. is important for skilled clinical reasoning and continued profeSSional growth. This is not to suggest that the only legitimate decisions and actions are those that can be conclUSively substantiated by cur rent research. as we hold the view that experience based non-propositional and personal knowledge. as discussed below. are equally important (Higgs et al.. 200la: Jones and Higgs. 2000). However.it is import ant to recognize the basis and biases of one's own views and that alternatives exist. This requires look ing beyond your own perspectives and contemplating other possibilities.some or which may even be beyond what is empirically known at the present time. Such open reflection about oneself (by therapists and patients) is no easy task. as Brookfield ( 2000. p. 63) points out: No matter how much we may think we have an accurate sense of our practice. we are stymied by the fact that we are using our own interpret ive filters to become aware of our own interpret ive filters! ... To some extent we are all prisoners trapped within the perceptual rrameworks that determine how we view our experiences. A selt� confirming cycle often develops whereby our uncritically accepted assumptions shape clin ical actions which then serve only to conl1rm the truth of those assumptions. Because of this. it is usually difllcult to explore your own assumptions effectively. Clinical reasoning in gen eral. and self-reflection in particular, is enhanced when we enlist the help of others. On this basis, Brookfield (2000) describes clinical reasoning as an inherently social process. Peers. teachers and also our patients can be erfective critical mirrors. as we can be to our patients, to foster the critical self-reflection necessary to promote change. Brookfield labels the reluctance most of us have for this (i.e. to exposing our reasoning to the critique of others) as 'impostorship': the deep feeling many clinicians have that they do not really under stand a problem or how best to manage it and their rear of being 'found out' by the patient and their col leagues. Acknowledging this realil)' is critical ir thera pists are seriously trying to improve their own clinical
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1 INTRODUCTION TO CLINICAL REASONING
reasoning. Section 3 discusses ways in which this bar rier can be broken down and in which critical reflection, and hence transformalive learning, can be facilitated. A key attribute of experts, and a necessary pre requisite to skilled clinical reasoning, is the affective disposition to think in this reflective manner. Such an affective disposition includes inquisitiveness, self confidence, open mindedness, flexibility, honesty, diligence, reasonableness, empathy and humility (Brookfield, 1987; Ennis, 1987; Fonteyn and Ritter. 2000; Jensen et al.. 1999). Clearly critical thinking. as well as being rational. is emotive.
Reasoning requires well-organized knowledge Research investigating the nature and development of expertise across a range of activities (chess, engineer ing, mathematics, medicine, physics, statistics) has consistently shown that it is not the command of any generic problem-solving strategies or how much knowledge is possessed that is critical; rather. it is how that knowledge is organized (Allwood and Montgomery. 1982; Arocha et aI., 1993; Bloom and Broder. 1950; Bordage and Lemieux, 1991: Boshuizen and Schmidt, 2000: Chi et al.. 1981: De Groot. 1965; Patel and Groen. 1986; Patel and Kaufman. 2000; Schmidt and Boshuizen. 1993). As previously discussed, humans store knowledge in chunks or patterns. Therefore, one can think of therapists' organization of lmowledge as the breadth and depth of their understandings and beliefs, held together in patterns acquired through both formal academia and personal experience. remembering that diagnostic patterns represent only a fraction of one's knowledge base. In fact. knowledge focussing purely on biomedical. diagnostic pathology is insufficient for full understanding and manage ment of patients' problems. Rather this propositional textbook knowledge must be integrated into a broader organization of non-propositional craft and personal knowledge. Understanding of patients' personal con texts, strategies of reasoning and intervention. and awareness of your own perspective. are important aspects of professional craft and personal lmowledge. It is beyond the scope of this chapter to explore this importanl topic of knowledge types and knowledge acquisition fully, and readers are referred to the work of Boshuizen and Schmidt (2000). Higgs and Titchen (2000). Higgs et al. (2001b) and Patel and Kaufman
(2000) for further discussion of these issues. For the purposes of this book, we will use the broad distinction (proposed by Higgs and Titchen (1995)) of propos i tional knowledge (or 'knowing that'-biomedical and biopsychosocial knowledge ratified by clinical trials and well-founded theories of professional practice) and non-propositional knowledge, including professional craft knowledge (procedural knowledge or 'knowing how', such as practical skills and strategies of enquiry, reasoning and intervention) and personal knowledge (knowledge derived from personal experiences, which shapes your own unique meaning perspectives and influences your interpersonal interactions, personal values and beliefs). Understanding and successfully managing patients' problems requires a rich organization of all three types of knowledge. Propositional LmowJedge provides us with theory and levels of substantiation by which the patient's clinical presentation can be considered against research-validated theory and practice. Non propositional professional craft knowledge allows us the means to use that theory in the clinic while providing additional, often cutting-edge (albeit with unproven generality) clinically derived evidence. Per sonal knowledge allows a deeper understanding of the clinical problem to be gained within the context of the patient's particular situation and enabling us to practise in a holistic and caring way. As important as knowledge obviously is to success ful clinical reasoning, improving one's organization of knowledge requires a clear understanding of how knowledge is acquired. Glaser (1984, p. 99) states that 'effective thinking is the result of conditionalized knowledge-the knowledge that becomes associated with the conditions and constraints of its use'. That is. knowledge is made particularly meaningful and accessible when it is created or acquired in the context for which it must be used (Cervero, 1988: Rumelhart and Ortony. 1977; Schon, 1983, 1987; Shepard and Jensen. 1990; Tulving and Thomson, 1973). In manual therapy. this means acquiring and constructing Jinks between propositional, professional craft and personal lmowledge in the context of real-life patient problems. This view is consistent with the stage theory of knowledge acquisition and development (Boshuizen and Schmidt, 2000). This proposes that medical students initially function predominantly on biomed ically dominated propositional knowledge structures. which gradually become encapsulated into clusters of higher-order concepts (e.g. clinical syndromes). In other
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PRINCIPLES OF CLINICAL REASONING IN MANUAL T H ERAPY
words, with clinical experience, textbook knowledge is eventually transposed into clinical patterns anchored within memory through real clinical experiences (Bosh uizen and Schmidt. 1 992, 2000: Schmidt et al.. 1 990, 1 992), The notion of an 'illness scri pt' is used to depict this higher-order knowledge structure (Feltovich and Barrows, 1 984). Illness scripts have three components: enabling conctitions: conditions or constraints under which a disease or problem occurs, such as personal, sociaL mectical, hereditary and environmental factors • fault: the pathobiological and psychosocial processes associated with any given disease or disability • consequences of the fault: signs and symptoms of the particular problem as well as its f unctional impact on the patient's life.
•
Even this probably oversimplifies the complexity of a clinician's knowledge organization. Virtually every characteristic of a patient ' s presentation (enabling conditions, rault and consequences) can be said to exist along a continu um. and judging the relevance of a particular feature often relates to its qualitative characteristics and perceived dominance within the presentation (Bordage and Lemieux , 1 986: Bordage and Zacks, 1984). Therefore. in addition to recogniz ing clinical presentations, therapists must also pos sess a broader understanding of the determinants of health and recovery. Patel and Kaufman ( 2000) challenge the model or knowledge encapsulation put forward by Boshuizen and Schmidt (2000), suggesting it represents an ideal ized perspective on the integration of basic science in clinical knowledge and argue that biomedical know ledge and clinical knowledge are two separate worlds. They suggest basic science has different Significance in different domains, and cite research which has demonstrated that even 'expert' medical clinicians have poorly developed biomedical knowledge. They propose that the key role played by basic science may not be in facilitating clinical reasoning per se but in facilitating explanation and coherent communica tion. The debate regarding the role of biomedical knowledge is equally important to manual therapy curricula, where some are grounded in promoting clinical decisions on the basis of the patient's presenling signs and symptoms (i.e. impairment based with con sideration of but not driven by biomedical factors) while others have pathology and biomedical con structs as the focus of assessment and management.
model ' We support a model of knowledge organization (and hence curriculum development) that draws on both traditions but is arguably broader in scope. An excit ing new model proposed by Gifford ( l 998b), the mature organism model (Fig. 1 . 2), provides a concep tual framework that we consider will assist therapists to take up this broader perspective. It depicts the interactions of the fundamental pathways (input. processing and output) into and out of the central nervous system (eNS) that are necessary lor survival and for the maintenance of health , as well as for the development and continuation of poor health (e.g. pain and disability). Input mechanisms (i.e. all sensory pathways) sam ple tissue health and conununicate this together with contexlual information about the environment. includ ing the immediate environment surrounding an injury and the ongoing environment that makes up a per son's pain or illness experience. The brain can then be said to scrutinize (both consciously and unconsciously) incoming information , along with existing engrams of past experiences, for processing to the output m(,c/I arzisms (i.e. somatic motor, autonomic, neuroendocrine, neuroimmune and descending feedback/conlrol sys tems). Importantly, how the person's health is then manifest via these output mechanisms (behaviourly, cognitively. emotionally and phYSiologically) depends, in part, on the contextual factors within the person's immediate circumstances, as well as past experiences that have contributed to the person's beliers , attitudes,
�r-----
Pain
percepti
on plus altered thoughts
Pain perception plus altered '"lings
cognitive dimension affective dimension
\ 1 /.
Gives Va.hM
10 expenence
t Further
=
=
alters
)
, Output = Altered behavio ... Altered physiology
li:;sue
Fig. 1 .2
The mature organism model. (With permission
from G iffo rd, L.S. (1 998b). Pain, the tissues and the nervous system: a conceptual model. Phys iotherapy, 84, 27-36.)
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1 INTRODUCTION TO CLINICAL REASONING
emotions and behaviours. In other words. even given the same extent of tissue injury or illness. no tvvo people will have exactly the same presentation because how they manifest their pain or illness is shaped in part by who they are. Hence. it is inadequate to focus simply on physical diagnosis. Managing patients' problems also requires understanding their unique pain or ill ness experiences (thcir understanding. beliefs. feelings. and coping strategies). While all input. processing and output mechanisms will be in operation in any state of ill-health. they will not all necessarily be impaired (i.e. contributing to the problem and/or counterproductive to recovery). Hence. manual ther apists must have the necessary knowledge organization and reasoning skills to distinguish between adaptive/ helpful and maladaptive/unhelpful mechanisms and responses. Even those problems that are seen as primarily nociceptive or residing in the tissues can be occurring alongside maladaptive psychological or behavioural 'responses '. which provide powerful barriers to active rehabilitation and the restoration of physical confidence. For example. a patient may have a lack of insight into the factors inOuencing their problem. which can create obstacles to their improve ment until addressed through narrative reasoning and communicative management. At a more physical levcl. prolonged stress not only can lead to increased levels of tissue sensitivity (i.e. secondary hyperalgcsia) but can also predispose to diminished tissue health via associated impairment within the neuroendocrine system (Butler. 2000: Gifford. 1 998c: Main et al.. 2000: Martin. 1997; Sapolsky. 1998). Here assessment of stress as a con tributing factor (along with the associated cognitive. behavioural and emotional effects) is clearly essential to understanding and managing the problem. Based upon this knowledge and reasoning. the clinician is then able to make sound decisions (for and with the client) that relate to assessment of the complete problem. including aSSOCiated cognitive. behavioural and emotional effects. and appropriate management strategies. Understanding and managing patients' problems requires a broad perspective of the multiple determinants of health and recovery. together with effective reasoning skills to apply that knowled ge. The mature organism model was developed to encourage and allow therapists (and patients) to be able to con sider openly and without prejudice the multiple factors and multiple levels involved in all pain presentations. it provides a broad conceptual framework from which
any of its elements (e.g. tissue mechanisms. pain mech anisms. effector mechanisms and psychosocial factors) and their respective clinical features or inter-relation ships can be explored fur ther (Jones et al.. 20(2).
• Hypothesis categories From the mature organism model. clinical patterns can be idcnlilled within the three categories of pain mechanisms (input. proceSSing and output). Under standing patients' problems requires understanding their unique presentations. including any activity/ participation restrictions. their individual perspectives on their experiences and the physical impairments they may have. This information can then be interpreted with respect to which pain mechanisms are dominant. what structures or tissues sources may be associated with specific physical impairments found. possible contributing factors. precautions. management and prognosis. This can be considered as representing 'categories of hypotheses' (see Table 1 .1) that musl be appreciated to understcUld fully patients and I'heir problems and to identify Clppropriate management strategies. The concept of hypothesis calegories was first introduced by Jones ( 1 9 8 7). but since then the specific categories considered important to manual therapy practice and the terminology used to des cribe them has continued to evolve (Butler. 2000: Christensen et al.. 2002: Gifford. 19 9 7; Gif ford and Butler. 19 9 7 : Jones. 19 9 2. 1995: Jones et al .. 2000. 2002; World Health Organization. 2001). These hypotheses should be formulated within broader conceptual models of health and disability, such as the mature organism model (Gifford. 1 9 9 8a) discussed here. Hypothesis categories can assist ther apists to relate the various elements of G ifford's model to the particular types of clinical decision required in contemporary manual therapy.
Activity and participation capability/restriction Activity restriction refers to difnculties an individual may have in executing activities. where participation restriction refers to problems an individual may have with involvement in life situations. These terms replace the previous terms disability and handicap. respectively. and are also synonymous with the 'dysfunction' hypothesis category. which has been previously used
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PRINCIPLES OF CLINICAL REASONING IN MANUAL THERAPY
Table 1 . 1
Hypothesis catego ries: categories of judgments
the patient can succeed with. Similarly, general phys
that assist in understanding the patient as a person and
ical and social reactivation commences from what the
thei r problem(s)
patient can do and from there aims to increase their
• Activity capability/restriction (abil ities and difficulties an
activity and participation levels progressively.
individual may have in executing activities) and Participation capability/restriction (abilities and
problems a n individual may have i n i nvolvement i n life situations)
Psychosocial factors: patients' perspectives on the i r experience
• Patients' perspectives on their experience
Patients' perspectives on their experience are synonym
• Pathobio/ogical mechanisms (tissue healing mechanisms and pain mechanisms)
ous with other terms used in the l i terature including
• Physical impairments and associated structure/tissue sources
their psychosocial status, their cogni tive and affective status. their psychological or mental status and. as discussed earlier in this c hapter, their pain or illness
• Contributing factors to the development and
experience. In reality. when a patient's activity and
maintenance of the problem
participation restrictions are identified. consideration
• Precautions and contraindications to physical
should be given to any physical , psychosocial or envir
examination and treatment
• Management and treatment
onmental factors that may be causing or contributing
• Prognosis
to those restrictions. Hence patients' perspectives is actu a l ly a su bcategory of 'contributing factors' dis cussed below. However, patients' perspectives on their
1997). The case contributors
experience has been listed as a separate hypothesis
in Section 2 use all of these terms somewhat inter
category simply to signpost the importance of this
changeably. Examples of activity restrictions include
area of understanding. which historically was not
functional d irficulties. such as ascending/descending
formally considered by manual therapists.
(e.g. Gi fford and Bu tler.
stair s . walking. lifting. prolonged sitting. etc. Partici
It is now well recognized that patients' perspectives
pation restrictions relate to the life involvement con
can be obstacles to their recovery. either as antecedents
sequences o f activity restrictions such as restrictions
to their pain states and activity/participation restric
i n participation in work or family d u ties or limitations
tions or as consequences (e.g. Butler, 2 0 0 0 ; Gifford.
in sport or leisure participation.
2 0 0 0 ; Main and Booker, 2 0 00; Main and Burton.
However, the patient's presentation cannot fully
2000; Main and Parker. 2000; Main et a l . . 2000;
be understood by only identifying activity and partici
Unruh and Henriksson. 2002). When attempting to
pation restrictions. Rath er, i t is equally important
understand the factors that may be causing or con
for therapists to recognize what their patients can do.
tributing to activity/partiCipation restrictions, patients'
that is their activity and participation capabilities.
perspectives ( understandings. beliefs , feel ings) must
Where restrictions will often correlate with patients'
be considered and screened for. If a particular per
goals. capabilities usually provide the point from where
spective has been hypothesized to be potentia l ly rele
retraining or reactivation must commence. To attend
vant as an an tecedent to a patient's pain state, the
only to restrictions can be discouraging and cogni
therapist must then. with the patient. endeavour to
tively behav iourally less effective in changing fu nction
u nderstand those factors in the patient's life that are
and performance. While procedural and comm u n ica
responsible for. or have contributed to. the identified
tive management may specificaJly target identified
perspective. These may include such things as past
physical impairments and unhelpful perspectives,
and present negative personal experiences (e.g. abu
respectively, facili tating fu nctional lifestyle imp rove
sive relationships. conflicting or disempowering medical
ment requires retraining or recommencement of mean
management) th at have contributed to shaping the
ingful activities (physical and social). If patients are only
patient's present beliefs, attributions and self-erficacy.
directed to those activities they can no longer perform. the result is often continued unsuccessful perform ance and fail ure. Therefore. management of specific
Pathobiological mechan isms
such as in adequate motor
Patients' activity and participation capabil ities/restric
control, is commenced from postures or activities that
tions. aSSOCiated pers pectives/psyc hosoci a l problems
physical impairments,
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1 INTRODUCTI ON TO CLINICAL R EASONING
and specific physical impairments are an expression of their pathobiology and life circumstances. This hypoth esis category comprises data about tissue and pain mechanisms. It was designed to facilitate reasoning that would include consideration of the mechanisms by which the patient's symptoms and signs are being initiated and/or maintained by the nervous system.
Tissue mechanisms Tissue mechanisms relate to issues of tissue health and stages of tissue healing. In particular. how well the patient's presentation 'fits' with what would be expected during the corresponding stage of the normal tissue healing process (Gogia. 1992: Hardy. 1989: Vicenzino et aI., 2002) is integral in developing a hypothesis of the pain mechanisms at work. For exam ple, an inllammatory presentation in a disorder that has been present for months or years should elicit consideration of other factors (e.g. behavioural, bio mechanical, maladaptive central processing) that may be maintaining an inflammatory process or mimicking one through central sensitization.
Pain mechanisms Pain mechanisms refer to the different input. process ing and output mechanisms underlying the patients' activity/participation restrictions, unhelpful perspec tives and physical impairments. Input mechanisms include the sensory and cir culatory systems that inform the body about the envir onment. both internally and externally. Examples of two input pain mechanisms are nociceptive pain and peripheral neurogenic pain (Butler, 2000; Galea, 2002; Gifford. 1998d; Wright. 2002a). The basic mechanism operating when a high-intensity stimulus, such as a pinprick, activates high-threshold primary afferent nociceptors resulting in pain is well recognized. The same mechanism is in operation with acute injuries, where injury to target tissues, such as ligament, muscle or connective tissue surrounding nerves, will result in nociceptive pain. Peripherally neurogenic pain refers to symptoms that originate [rom neural tissue outside the dorsal horn or cervicotrigeminal nucleus, such as may occur with spinal nerve root compression or peripheral nerve entrapment. Both nociceptive pain and peripherally evoked neurogenic symptoms have a familiar pattern of presentation. with a predictable stimulus-response relationship, enabling consistent
aggravating and easing factors to be quickly identified by patient and therapist. Processing of input occurs in the CNS, and therap ists should be aware of the clinical features indicative of abnormal CNS processing. For example. abnormal processing can occur in patients displaying centrally evoked symptoms (Butler, 2000; Gifford. 1998e; Wright, 2002b), where the pathology lies within the CNS. Here the symptoms provoked from a past target tissue injury can be maintained even after the ori ginal injury has healed and the symptoms may no longer behave with stimulus-response predictability. Another example of the clinical relevance of the pro cessing mechanisms is evident when we consider that pain and disabUity have more than just physical and sensory dimensions (Merskey and Bogduk. 1994). Pain and activity/participation restrictions in all their forms also have affective (e.g. emotional impact such as fear, anxiety and anger) and cognitive (e.g. under standing , beliefs and attributions about the pain or disability) dimensions. Patients' feelings and thoughts about their pain and activity/participation restric tions can significantly contribute to the maintenance of their problems and influence the speed of the recovery (Butler, 2000; G ifford, 1998c; Main and Booker, 2000). While all pain can be exacerbated chemically by emotional and/or general physical stress, in a central pain state both physical and psychosocial stress are thought to be Significant contributing factors in maintaining the pain. Hence, a patient's perspectives, including their cognition (e.g. understanding of the problem and intervention required) and affect (e.g. feelings about the problem, management and effects on their life), are important dimensions of all pain states but are particularly significant in central pain. Ouput mechanisms operate through the motor, autonomic, neuroendocrine and immune systems (Butler. 2000; G ifford, 1998c). The somatic motor mechanism involves altered motor activity (increased or decreased) and movement patterns in response to pathology, but also learning. While painful pathology can inhibit muscle function and lead to altered move ment patterns (Hides and R ichardson, 2002) , many postural and movement abnormalities are associated with problems of motor learning as well as motor control (Shumway-Cook and Woollacott, 2001). These faulty movement patterns may be acquired through habitual postures and activities of life or may develop as a consequence of maintained pain.
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PRINCIPLES OF CLINICAL REASONING IN MANUAL THERAPY
The au tonomic mechanism is a controversial output system in that features of abnormal sympa thetic activity are common in some chronic pain states. although the underlYing pathology is still u nclear. While the sympathetic nervous system is normally active in all pain states. it can be pathologically active in some. This pathological activity can contribute to disability. impairment and maintained pain (B utler. 2000; Gifford, 1998c: Wright. 2002b).
Other conseque nces of a stressed system The neuroendocrine system is responsible lor the regu lation of metabolism, water and salt balance, blood pressure, response to stress and sexual reproduction. Of these functions, its response to s tress is pHrticul arly relevant given that many patients have elements of stress that are a predisposing factor to. or lhe result of. their problems. Like the sympathetic nervous system. the neuroendocri ne system is responsive to our thou ghts and feeli ngs. Stress, for example. triggers a chain of events from the hypothalamus to the adrenal cortex that enables the appropriate channelling of energy for an individual to escape a perceived threat. However. maintained stress, as is common in so many chronic pain states, can result in mal adaptive neuroendocrine activity that is detrimental to tissue health and impedes tissue recovery (Butler. 2000: Giflord, 1998c: Martin, 199 7 ; Sapolsky, 1998). The neuroimmune system is an output system with close links to the brain. the sympathetic nervous system and the endocrine system. ChroniC pain, deconditioning or overconditioning and psycho logical impairment can interfere with normal immune and heali ng processes via this system (Butler, 2000: G ifford, 1998c: Mackinnon. 1999: Mar tin, 1997). The pathobiological mechanisms hypothesis cat egory is invaluable in focussing thinking to the devel opment of hypotheses about where within the nervous system symptoms are being produced and main tained, and what other sy stems rrtight be affected. If a patient presents with a 'normal' adaptive pain mech anism, wherein symptoms are the result of pathology of the implicated local tissues, it is appropriate to determine the precise physical impairment/diagnosis and identify a specillc site to direct manual treatment. However. when pain symptoms are the result of 'abnormal' maladaptive pain states, resulting from, and maintained by, altered CNS processi ng. manual
therapists must steer away from the sole usc of a lissue based paradigm and instead employ more holistic. less tissue-specific managemen t strategies. While physical impairments may still req uire attention, these patient presentations criticaJly require promotion of cognitive behavioural. healthlfitness and motor control change through adultltransformative lear ning. These issues are presented only briefly here: while there are numer ous basic pain science papers that support these con cepts. readers are referred to the excellent texts by Butler (2000). Gifford ( 1998f. 2000), Main and Spanswick (2000b) and Strong et aL (2002) for a more thorough review of pain mechanisms and associated strategies of management. Physical i m pai rments and associated structures/tissue so urces
A manual therapy diagnosis should be one that cap tures the therapist's understanding of the patient and the patient's problem(s). This would include the ther apist's judgment regarding each of the hypothesis categories discussed here. In our v iew, it is not satis factory simply to identify structures involved, as this alone does not provide sufficient information to understand the problem and its effect 011 the patient. nor is it sufficient to justify the course of management chosen. The manual therapy diagnosis must include a hierarchy of considerations from the activity/partic ipation restrictions, and any associated unhelpful perspectives or psychosocial problems, to specific physical impairments identified and their associated structure/tissue sources. Specific physical impairments in a musculoskeletal context are regional neuromusculoskeletal abnormal ities detected through the physical examination, such as lirrtited hip active movement, poor transversus abdominis motor control. or excessive glenohumeral joint mobility. The associated structure/tissue sources of physical impairments refers to the actual structure or target tissue from which the symptoms or signs are hypothesized to be emanating, with particular atten tion (where possible) to the pathology present within that str ucture. Joints. muscles. ligaments and even nerves are examples of target tissues that can be injured and give rise to pain and physical impairment. Clues to specifiC physical impairment sources are available from the area. description. behaviour and history of the sy mptoms. These hypotheses are then tested fur ther in the physical examination, where
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1 INTRO DUCTION TO CLINICAL REASONING
specific tests of structure and tissue impairment
by its potentia l effect on a specific structure. such as the intervertebral disc. the therapist can easily be mis
are used . Interpretations regarding specilk sources of the
led i n attributing the improvemen t i n extension to a
symptomslimpairments must be made with reference
change in the disc sensitivity, structure or mechanics.
to the domimmt pain mechan ism(s) hypothesized.
This is. of course. an error of reasoning in that such
When nociceptive and peripheral neurogenic mech
changes are only inferred.
anisms are dominant. local tissue impairment provides a more accurate
reflection of
the specific tissues
or more concern is that solely tissue-based reason ing tends to promote inflexibil i ty of management
involved . However. care is needed when processing
stra tegies. Our preference. like others (e.g. Maitland
mechanisms are dominant (i. e. maladaptive) as the
et ai . , 2001; Sarhma nn.
associated secondClry hyperalgesia ( CNS-maintained
tify potentially releva nt impairments and then hypoth
200 2). is for therapists to iden
Lissue sensitivity) can lead to false-positive cli nical f1nd
esize about potential sources of those impairments.
ings (e.g. tender tissues. painful movements. etc.). which
Man agement is then directed to the impairment.
can then lead to incorrect conc l u sions rega rding the
\) \) � ). H. in
a l though this may include treatment to specific tissues.
II
This relates directly to the value of the disablemenl
centrClI pain stClte. t hese false posi t i ves are i n terpreted a s
model (Guide to Physical Therapy Practice. 2 0( H ) a nd
source of the symptoms (:l.usma n . I \) \) 7 . I implicating peripheral target t issues symptoms. interven tion strCltegies
,IS
a local source of
biopsychosocial model ( M a in and Spanswick. 2 ( ) ( ) ( )a:
m ay
then be i n appro
Wadel ! .
pri ately applied to these target t i ssues. resu l t i n g i n poor
1\) \) � ) or c l i n ical practice.
whereby physicci l
treatment is guided by a c t i vity/par t i cipat ion rest r ic
outcomes and possibly even contributing to the mainte
tions and ident illed impairments Clnd not solely by diag
nance of the problem ( Butler. 2( )OO; Watson. 2 0()O).
nostic labels ( M aitland et a l .. 20(H ). The application
Attempting to hypothesize about specific struc tures
of thorough assessmen t and balanced reasoning, in
such as contractile tissues. specific joints or neuro
which identified impairments are considered in con
gen ic pain is i mportClnt. and someLimes even critical
j u nction with known and hypothesized patho logy. wiU
in order to ensure safety (e.g. vcr tebrobasilar insuffi
enable therapists to deliver effective treatments while
ciency. spinal cord pathology or joint instability).
continuing to improve understanding and to expand
However. in reali ty, it is often n o t possible to confirm
and. eventual ly. validate their clin ical impress ions.
c linically which specific tissues are at fa ult. Even with the assistance of advanced dia gnostic or imaging pro cedures where pathology can be demonstrated. con
Contributi ng factors
firmation of those tissues as being the true source of
Contributing factors are any predisposing or associated
the symptoms is often impossible. Many degenerative
factors involved in the development or maintenance
changes evident on the various imaging procedures
of the patient's problem. These factors may be environ
are asymptomatic and, therefore, may be minimally
mental.
relevant or even completely unrelated to the patient
chanical and even hereditary. For example. an inllamed
problem a t hand. It is not unusual for even the most
subacromial bursa may be the nociceptive source of the
skilful and experienced manual therapist to achieve
patient's symptoms and impaired movements. but com
psychosocial,
behavioural,
physical/biome
only a relative localization of the source of the symp
monly either a tight posterior glenohumeral capsule
toms (e.g. lower cervical spine versus local shoulder
or 'vveak' scapular rotator force couples contribute to
tissues ) . even with a detailed evaluation and meticu
altered kinematics that predispose the patient to bursal
lous reassessment of chosen interven tions. Therefore,
irritation. Similar ly, the source of the symptoms may
a balance is required in the specificity of hypotheses
be the CNS and the contributing factors might be the
generated regarding the source of the symptoms. The
patient's unhelpful perspectives (e.g. understanding.
therapist must recognize the limitations of such clin
beliefs and feelin gs) . secondary to a combination of
ical diagnoses a n d take care to avoid limiting manage
conflicting health-professional advice a n d in effective
ment only to proced ures directed to specific tissues.
coping strategies for a stressful work a n d family envi
For example, while mobilization or exercise to improve
ron ment. The obvious importance of conSidering con
an impairment in active lumbar extension can be
tributing factors relates to management options. Clearly
substantiated through reassessment of the extension
for many nociceptive dominant problems, treatment
impairment, when the same treatment is only j u stifted
directed to the actual impairment or source is helpful
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PRINCIPLES OF CLINICAL REASONING IN MANUA L T HERAPY
(e.g. mobilization for a stif r. painful movement or con trolled loading of a tendinopathy). In other cases, such as symptomatic hypermobile/unstable spinal or periph eral jOints , while some treatment in the form of pain relieving measures directed to the source of the symptoms may be indicated. the focus of treatment needs to address the contributing factors (e.g. retrain ing motor control or mobilization of adjacent areas of hypomobility to reduce the load on the symptomatic tissues). Ultimately, it is only through systematic reassessment of the management provided that the optimal balance of treatment directed to sources and contributing factors is determined. When maladaptive eNS processing is recognized as the dominant pain mechanism. management must be directed to the various patient perspectives. behaviours or physical impairments hypothesized to be contribut ing to the maintenance of their activity/participation restriction. However it is often difficult to be certain whether an apparent central sensitization is being driven by external contributing factors or whether sig nificant pain and physical impairment may. in fact. be contributing to the patient's stress and psychosocial problems. Again. reassessment is the manual therap ist's guide to malting this deCision. With a true noci ceptive problem , the signs and symptoms will improve , and continue to improve. in a predictable manner with time and/or skilled treatment. In contrast. when the patient's symptoms do not improve or maintain improvement from a trial of treatment directed toward a par ticular impairment or hypothesized nociceptive source. management must be redirected to the different contributing factors hypothesized to be maintaining the central sensitization (Kendall and Watson , 2000).
Precautions and contraindications to physical examination and treatment Hypotheses regarding precautions and contraindica tions to physical examination and treatment serve to determine the extent of physical examination that may safely be undertaken and whether physical treat ment is contraindicated or limited in any way by safety conSiderations. Such decisions are determined by consideration of many variables including: the dominant pain mechanism the patient's perspectives and expectations • the severity of the disorder • •
• • • • • •
the irritability of the disorder whether the disorder is progressive (and its rate of progression) the presence of specific pathology (e.g. rheumatoid arthritis. osteoporosis) the stage of healing general health the suspicion of more sinister pathology (e.g. unexplained weight loss).
If treatment is indicated. the therapist must decide whether any constraints to physical treatment exist (e.g. pain-provoking versus non-provocative treat ment techniques and the amount of force that can safely be used). A key examination strategy for identi fying potential risk factors is the use of screening questions directed to red flags , or clinical signs and symptoms suggestive of possible serious pathology. Redf/ags exist with respect to serious spinal pathology (Roberts , 2000). vertebrobasilar insuffiCiency (Barker et aI. , 2000; Di FabiO. 1 999; Rivett. 1997). certain paediatric disorders (e.g. slipped capital femoral epi physis). and the presence of non-musculoskeletal dis orders masquerading as musculoskeletal dysfunction (Boissenault. 1995; Goodman and Snyder. 2000).
Management relates to hypotheses regarding inter ventions for improving the overall health of the patient. as well as consideration of specific manual therapy measures and techniques. As with all hypothesis cat egories , management decisions should not be based on any single facet of the patient's presentation. Rather, information gleaned through the history and physicaJ examination. in addition to the patient's response to trial treatments, will collectively determine the pathobiological mechanisms. relevant iinpairments (and sometimes sources). contributing factors and the need for caution. Management decisions are then gUided via the weighting of evidence from each of these other hypothesis categories, with ongoing man agement informed through the reassessment process.
Prognosis Estimating patient responses and outcomes is predict ive reasoning (Edwards. 2001; Jones et al.. 2000). Manual therapists must be able to outline possible
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future scenarios based on consideration of the patient's presentation. responses to management interven tions and available evidence (clinically and research based). The likelihood of lhese scenarios eventuating depends on the nature of the patient's disorder and the patient's ability and wil lingness to make the neces sary changes to those factors contributing to the problem (e.g. physical. lifestyle. personal perspectives/ psychosocial). Prognosis should be considered with regard to the patient's broader prospects for recovery and return to function and/or the patient's potential for learning ' (e.g. changing beliefs and behaviours). which for some may include learning to live and cope with the problem. Like all clinical decision making. prognosis is an inexact science. with both positive and negative prognostic I"eatures typica lly being present in most patient's presentations. Factors that will assist in judging a patient's prognosis include: • •
• •
• • • •
the patient 's perspectives and expectations the patient's social, occupational and economic status the mechanisms of symptoms involved the balance of mechanical versus inflammatory components the irritability of the disorder the degree of damagelimpairment the length of history and progreSSion of the disorder the patient's general health and presence of pre existing disorders.
Psychosocial risk factors. or yellow flags (e.g. patients' beliefs/coping strategies. distresslillness behaviour. and willingness to change). should be screened for with all patients (Kendall et al. . 1 9 9 7 ; Main and Burton, 2000: Watson and Kendall. 2000). More recently, Main and colleagues (Main and Burton, 2 000: Main et al. . 2 000) have further delineated the occupational com ponent of the yellow flags into blue and b lack flags. BILle flags are derived out of the stress literature. They represent perceived features of work that are generally associated with higher rates of symptoms. ill-health and work loss and which may constitute a major obstacle to the patient's recovery. They are characterized by the follOWing features: • • • • •
high demand and low control unhelpful management style poor social support from colleagues perceived time pressure lack of job satisfaction.
Interestingly, a person's perception may be more sig nificant than any objective characteristics of the workplace. again highlighting the importance of psy chosocial screening in manual therapy assessment. Black flags include nationally established policy concerning conditions of employment and sickness policy, as well as the specific working conditions of a particular employer: •
•
•
national rates of pay - negotiated entitlements (benefit system . wage reimbursement) employer sickness policy restricted duties policy management style organization size and structure trade union support content-speci fic aspects of work ergono mic (e.g. job heaviness, lifting Irequency, postures) temporal characteristics (e.g. number of work ing hours. shift pattern).
Through the course of the patient examination and ongOing management. screening for red, yellow. blue and black flags. along with the physical examination and response to initial trial treatments. will assist the therapist in formulating a prognosis and determining the appropriate mode of management. Successfully obtaining this breadth and depth of information requires specific enquiries. For example, has the ther apist assumed or explicitly explored what the patient wants to do in the future? Further. with consideration of the patient's meaning perspective. is the patient's personal construction of their situation distorting their own view of what the future holds for them and thus distorting their decision making? Therapists must be adept with the various strategies of reasoning (e.g. diagnostic. narrative. collaborative) in order to achieve the necessary level of understanding required to make decisions effectively within each of the different hypothesis categories. The reflective therapist will not only weigh the full spectrum of prognostic variables in j udging a patient's prognOSis but also critical ly re-examine the j udgment when ongoing reassess ment reveals the projected prognosis is not being met. Often manual therapists' assessment and manage ment decisions require an element of ethical reason ing. The scope of ethical decisions faCing manual
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therapists can range from decisions regarding use of potentially aggravating or even life-threatening pro cedures to decisions of patient autonomy, informed con sent, confidentiality, interprofessional relationships, practitioner-client relationship , resource distribution/ cost containment and a myriad of day-to-day decisions that underpin quality care. Clinical decisions that are based solely on the therapist's judgment of what is best for the patient are not consistent with ethical decision making. Rather, decisions made for the client must be made with the client. We take the view that, as in other areas of decision making, competent man ual therapists should be guided by a combination or community and professional standards (e.g. profes sional association ethical guidelines) applied in a context-sensitive manner as learned through previ ous experiences. We are, therefore , in accord with Benner (1991. p. 18) who states, 'Ethics in health care must start with a practice-based understanding of what it is to be a person, what constitutes the rela tionships among the health care worker, patient, family, and community, and what constitutes care and responsibility toward one another'.
Summary Manual therapists must work with a multitude of patient and problem presentations, many of which defy simple technical solutions. Contemporary man ual therapy requires that therapists not only have a rich organization of clinically relevant biomedical and psychosocial (Le. biopsychosocial) knowledge but also have skills in diagnostic, narrative, collaborative, prog nostic and ethical reasoning. Successful application of that knowledge then requires advanced procedural
(e.g. manual techniques and motor control retraining) and communicative (listening, clarifying, explaining, negotiating and counselling) skills. Underpinning all dimensions of clinical reasoning is the abilily of therap ists to recognize relevant cues (behavioural, psycho logical, physical. social. cultural. environmental, etc. ) and their relationship to other cues, and to test or verify these clinical patterns through further exam ination and management. In this sense, clinical reasoning in manual therapy is hypothesis oriented. For all the various strategies manual therapists util ize in their patient management, perhaps the most pervasive are our skills in teaching. Reasoning related to teaching is enhanced when therapists understand concepts and strategies of learning theory, particu larly transformative learning, which aims to change individuals' meaning perspectives. How well practi tioners learn from the results of their decisions depends on the thoroughness of their deliberations and the time and attention given to their conscious rel1ection. There are no short cuts to becoming an expert manual therapist. However, it is our view that critical, rel1ective and collaborative reasoning will improve the breadth and depth of clinical patterns (regarding the person and the problem, including management strategies) that can be recognized and applied. It has been estimated that master chess play ers have some 50 000 configurations of chess that they can recognize (Posner. 1988). While the breadth of clinical patterns that experts such as those repre sented in this book possess has not been calculated, it is reasonable to assume their organization of clin ically relevant knowledge would be equally stagger ing. It is our opinion that expertise is not acquired by experience alone. Rather. expertise is developed, in part, through skilled rel1ective reasoning.
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Patel. V. L. and Kaufmann. D. R. (2000). C l i n ical reasoning and biomedial knowledge: implications for teaching. In Clinical Reasoning i n the Health Professions. 2nd edn (J. Higgs and M . Jones. eds.) pp. 3 3--44. Oxford: B u tterworth-Heinemann. Posner. M . l . ( 1 9 8 8 ) . introduction: what i s it t o b e a n expert) [n T h e Nature of Expertise (M .T. H. Chi. R. Glaser and R.). Farr. cd s.) pp. xx ix-xxxvi. Hil lsdale. N): Lawrence Erlbaum. Rivett. D.A. ( 1 9 9 7 ) . Preventing neurovascular complications of cervical spine manipulation. Physical Therapy Reviews. 2. 2 9- 3 7. Rivett. D. A. and Higgs. ). ( 1 9 9 7 ) . Hypothesis generation i n t h e clinical reasoning behavior of manual therapists. jou rnal o[ PhySical Therapy Education. 1 1 . 40--4 5 . Roberts. L. ( 2 000). Flagging the danger signs of low back pain. [n Topi cal issues of Pain 2 . Biopsychosocia l Assessment. Relationships a n d Pain (L. Gifford. ed . ) pp. 69-8 3 . Falmouth. U K : CNS Press. Rumelhart. D.E. and Ortony. E. ( 1 9 7 7 ) . The representation of knowledge in memory. [n Schooling and the Acquisition of K n owledge ( R.C. Anderson. R .j. Spiro and W.£. Montague. eds.) pp. 9 9-1 3 5 . H i l lsdale. Nj: Lawrence Erlbaum. Sab.rmann. S.A. (2002). Diagnosis and Trea tment of Movement Impairmen t Syndromes. S t Louis. M [ : Mosby. SapolskY. R . M . ( 1 9 9 8 ) . Why Zebras Don't get Ulcers. An Updated Guide to Stress. Stress-Related Diseases. and Coping. New York : Freem a n .
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Schmidt. H . G . a n d Boshuizen. H . P A . ( 1 9 9 3 ). On acquiring expertise i n medicine. Educational Psychology Review. 5 , 2 0 5-22 l . Schmidt. H.G . . Boshuizen. H.P.A. and Norman. G.R. (J 9 9 2 ) . Rellections on the nature of expertise in medicine. [n Deep ModeIs for Medical Knowledge Engineering (E. Keravnou. ed.) pp. 2 3 1-248. Amsterdam: Elsevier Science. Schmidt. H.G .. Norman. G . R . and B os h u izen. H . P. A . ( 1 9 9 0 ) . A cognitive perspcctive on mediCal expertise: theory and implications. Academic Medicine. 6 5 . 6 1 1-6 2 1 . Schon. D. A. ( 1 9 8 3 ) . The Reflective Practitioner: How Professionals Think i n Action. London: Temple Smith. Schon. D. A. ( 1 9 8 7) . Educa ting the Rellective Practitioner. San francisco. CA: jossey-Bass. Shendell -Falik. N. ( 1 990). Creating seJf care u n its in the acute care setting: a case study. Patient Education and Counselling. I S . 39-4 5 . Shepard. K . E a n d Jensen. G . M . ( 1 9 9 0 ) . Physical therapist curricula for the 1 9 90s: educating the rellective practi tioner. Physical Therapy. 70. 5 6 6-5 7 7 . Shu mway-Cook. A. a n d Wool l acott. NUl . ( 2 00 1 ). Motor Control: Theory and Practical Applications. 2nd ed n. Bal timore. M D : Lippincott. Williams & Wilkins. Sluijs. E.M. ( 1 9 9 1 ). Patient education in physiotherapy: towards a planned approach. Physiotherapy. 77. 503-5 0 8 . Strong. J . ( 1 9 9 5 ) . Sel l�erficacy and the patient with chronic pain. In Moving i n on Pa in ( M . Shacldock. ed . ) pp. 9 7- 1 0 2 . Chatswood: Bu tterwort.h-Heinemann. Strong. J . . Unruh. I\.. M . . Wright. A. and Baxter. G.D. (eds.) ( 2 0 0 2 ) . Pain. A Textbook for Therapists. Edi nburgh: Churchi l l Livingstone. Tulving. E. a nd Thomson. D.M . ( 1 9 7 3 ) . Encoding specificity a n d retrieval processes in episodic memory. Journal of Psychological Review. 80. 3 5 2-3 7 3 . U n r u h . A . M . a n d Henriksson. C. ( 2 0 0 2 ) . Psychologica l . environ mental and behavioural dimensions of the pain experience. In Pain. A Textbook for Therapists O. Strong. A . M . Unruh.
A. Wright. and G . D. Baxter. eds.) pp. 6 5-80. Edi n b urgh : Churchill Livin gstone.
PRINCIPLES OF CLINICAL REASONING IN MANUAL THERAPY
Vicenzino. B .. SOli viis. T. and vVright. A . ( 2 0 0 2 ) . M usc uloskeletal pain. I n Pain. A Textbook for Therapists U. Strong. A . M . Unru h . A. Wright. and G.D. Baxter. eds.) pp. 3 2 7-349. Edinburgh: Ch urch ill Livi ngstone. Wadel l . G. ( 1 9 9 8 ) . The Back Pain Revol ution. Edinburgh: Churchill Livingstone. Watson. Ie ( 2 000). Psychosoci a l predictors or o utcome rrom l o w back pa in. In Topical Issues of Pain 2 . Biopsychosoci a l Assessment. Helationships and Pain (L. Gifford. ed. ) pp. 8 5- 1 0 9 . Falmouth. UK: CNS Press. Watson. P. a nd Kendall. N. ( 2000). Assessing psychosoci a l yellow flags. In Topical Issues of Pa i n 2.
BiopsychosociaJ Assessment. Relationships and Pain (L. Gifford. ed ) pp. 1 1 1 -1 2 9 . Falmouth. UK: CNS Press. World Health Organization (200 1 ) . ICF Checklist Version 2 . 1 a. Cli n ician Form for International Classification of Functioning. Disability and Health. Geneva: WHO. [Ava ilable online at http://ww w. who.inticiassifIcation/icfl checklist/icf-checkl ist.pdf. April 1 5 . 2002.] Wright. !\. (2002a). Neuropatbic pain. In Pai n . A Textbook for Therapists (J. Strong. A . M . Unruh. A. Wright. and G . D. Baxter. ed s.) pp. 3 5 1- 3 7 7 . Edinburgh: Churchill Liv ingstone. Wright. A. ( 2 002b ) . Neurophysiology of pain and pain mod ula tion . In Pa in.
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A Textbook for Therapists (J. Strong. A.M. Unruh. A. Wright. and G.D. Baxter. eds.) pp. 4 3-64. Edinburgh: Churchill Livingstone. Zusman. M . ( 1 9 9 7 ) . Instigators of activity intoleronce. Manual Therapy. 2. 75-8 6 . Zusman. M . ( 1 9 9 8 ) . Structu re-oriented beliefs and disability due to back pai n. Austra l ian Journal of Physiotherapy. 44. 1 3-20.
Clinical reasoning in action: case studies from expert manual therapists II II
Back and bilateral leg pain in a 63-year-old woman
27
Ongoing low back, leg and thorax troubles, with tennis elbow and headache
36
Chronic low back pain over 13 years
II II II II III III
II II
51
Dick Erhard and Brian Egloff
Unnecessary fear avoidance and physical incapacity in a 55-year-old housewife
A chronic case of mechanic's elbow
61
II
87
Toby Hall and Brian Mulligan
Chronic low back and coccygeal pain
103
Paul Hodges
Ankle sprain in a 14-year-old girl
123
III II
Gary Hunt
Headache in a mature athlete
135
motor vehicle accident
215
Erl Pettman
A judge's fractured radius with metal fixation following an accident
229
A university student with chronic facial pain
243
Mariano Rocabado
Adolescent hip pain
261
Shirley Sahrmann
A software programmer and sportsman with low back pain and sciatica
275
An elderly woman 'trapped within her own home' by groin pain
work and sport
312
Patricia Trott and Geoffrey Maitland
Thoracic pain limiting a patient's secretarial 149
Chronic peripartum pelvic pain
Diane Lee
326
John van der Meij, Andry Vleeming and Jan Mens
Bilateral shoulder pain in a 16-year-old long-distance swimmer
161
Medial collateral ligament repair in a professional ice hockey player
Patellofemoral pain in a professional 194
ED Ell
Acute on chronic low back pain
III
340
Richard Walsh and Stanley Paris
A non-musculoskeletal disorder masquerading as a musculoskeletal disorder
180
David Magee
Jenny McConnell
Craniovertebral dysfunction following a
Tom Arild Torstensen
Gwendolen Jull
tennis player
206
Robin McKenzie and Helen Clare
Robert Pfund in collaboration with Freddy Ka/tenborn
Louis Gifford
Mary Magarey
III
Self-management guided by directional preference and centralization in a patient with low back and leg pain
Mark Bookhout
David Butler
II
III
352
Peter E. Wells
Forearm pain preventing leisure activities
358
Israel Zvulun
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25
Back and bilateral leg pain in a 63-year-old woman Mark Bookhout
�
SUBJECTIVE EXAMINATION
A 63-year-old retired female (Francis) presented to our clinic with a chief complaint of low back pain and bilateral lower extremity pain. She had led an active lifestyle and was happily married. with her husband in good health. She played tennis. travelled and was taking computer classes. Francis gave a history of low back pain, chronic in nature, resulting from a lifting injury 22 years previ ously. At the time of her original inj ury, she was d iag nosed by an orthopaedic surgeon as having a herniated lower lumbar disc, but she was unaware of the actual level of herniation. Francis reportedly had been able to self-manage fairly well with intermittent low back pain until her most recent episode, which commenced approximately 4 months before her first consultation with me. At that time. s he developed sharp shooting pains into both of her lower extremities without any apparent trauma or predisposing factors that she could recaU, otber than the fact her symptoms were exacer bated by playing tennis. Francis also noted an increase in her low back pain but reported that her leg pain was more severe and d isturbing to her because she had not had any leg symptoms previously. The pain was described as radiating down into the bu ttocks and the posterior legs as far as the calves and heels, but not into the reet. seemingly following an LS or Sl dermatomal distri.bution. Francis was seen by a physician, who ordered an enhanced computed tomography (CT) scan of the lum bar spine with myelography. The scan revealed central spinal canal stenosis along with mUltiple level lumbar
degenerative disc disease and a grade I spondylolisthe sis at LS-S1. Francis then had an epidural steroid injec tion (4 months ago), which gave her some relief with a notable decrease in pain intenSity, but the distribution of the referred pain was unchanged. She reported the pain had been relieved approximately 40-50% by the epidural injection. Subsequently she was placed on an anti-inllammatory medication (nabumetone). which she was still taking when therapy was initiated . Francis reported that the medication helped her quite a lot. decreasing the intensity of her pain by another 20%. She had not received any previous physical therapy treatment ror her condition and she was self-referred. A physician had apparently told her that she might be a surgical candidate and her primary goal in seeking physical therapy treatment was to avoid having lumbar spine surgery if at all possible and to be able to continue to play tennis, her main passion in life. Francis reported that her back pain was aggravated by slow wa lking, prolonged standing greater than 1 hour. playing tennis and bending slightly forward as in doing her dishes or vacuuming. She reported that her leg pain was specifically accentuated during and after playing tennis, and she could only play 15-20 minutes before noting a significant onset of leg pain. Sleeping was reportedly not a problem and neither was sitting, but lifting heavy loads aggravated her back pain. Coughing and sneezing had no effect on her symptoms. Overall, she rated her level or pain at 4110 but it could l1uctuate from 0/10 on a good day to 5/10 on a bad day.
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27
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
The medical history was otherwise unremarkable.
many years previously and had also been hospitalized
There was no paraesthesia and no reported subjective
for an automobile accident with facial injuries at
numbness. She denied any bowel or bladder problems
17 years of age. but there were no reported residual
or any history of trauma. Francis also denied any
problems. Francis was particularly distressed about
recent weight gain or loss and her medical history
her inability to play tennis without pain and was
was negative for high blood pressure, tuberculosis,
somewhat fearful of the possibility of lumbar surgery,
anaemia, cancer, heart problems, depression, thyroid
which she strongly wanted to avoid. There did not
problems, emphysema. hepatitis, asthma, kidney dis
appear to be any other
ease or diabetes. She had had one epileptic seizure
factors.
significant psychosocial
REA SONING DI SCU S SION AND CLINICAL REA SONING COMMENTARY
D
Please comment on the range of hypotheses you
jOints and sacroiliac joint were noted, I felt that her
had at this stage regarding possible sources of
dominant pain mechanism was probably nociceptive
her symptoms. Which of these did you think was
arising from faulty and dysfunctional joint mechan
most likely and what was the pattern within the
ics. I did not find evidence to support involvement of
subjective examination that supported this
any pathological central pain mechanisms or dys function within the output systems (i.e. sympathetic,
principal hypothesis!
endocrine, immune, motor).
• Clinician's answer
Please discuss your reasoning with respect to
I felt that the patient had several possible sources for
likely contributing factors to this most recent
her symptoms, including central or bilateral lateral
episode of symptoms.
foraminal stenosis at LS-S1 (with associated neuro genic claudication), secondary to spondylolisthesis at LS-Sl, and/or dynamic instability at LS-S1 secondary
• Clinician's answer
to lumbar degenerative disc disease. I also thought
r felt that the most likely contributing factors to this
that mechanical dysfunction of the lower lumbar
recent episode of symptoms were the patient's age,
facet joints could result in the described pain referral
the IU<ely weaknesslineffectiveness of her core trunk
pattern into the lower extremities. r initially believed
muscular stabilizers and stiffness of the facet joints,
that the primary source was most likely dynamic
all combined with continued aclivity (i.e. playing ten
lumbar instability at LS-S1 since in her subjective
nis on a regular basis) that her spine (structurally and
history she reported an accentuation of her symptoms
dynamically) was unable to cope with.
with activity (particularly the leg pain), especially with playing tennis.
lEI
II
Were there any features within her subjective examination that signalled the need for caution
Did you have any reason at this stage to suspect
in your phYSical examination and treatment!
involvement of 'pathological' central pain mechanisms in her presentation! Please briefly discuss your thoughts on the dominant pain mechanisms you hypothesized were evident from her presentation thus far.
Clinician's answer There were no features within the subjective exam ination that signalled the need for caution or impli cated any contraindications to my examination or treatment. Her disorder seemed to present as having a
Clinician's answer
low irritability level with no significant neurological
After my objective clinical examination in which sig
flDdings anel certainly no progressive neurological
nilkant joint restrictions in the lower lumbar facet
findings.
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2 BACK A N D BI LATERAL LE G PA I N IN A 63-YEA R-O LD W OMAN
Clinical reasoning commentary
The clinician's answers to these questions reflect the breadth or his reasoning through the subjective examinatioll, Importantly, he does not simply accept what the patient spontaneously ofl'ers further by screening for other types of symptom, aggravating factors and general health considenl tions. j\llulliple structures are considered as possibly being responsible lix the patient's symptoms and these are .directly linked to associated structural
tEl
(e.g. spondylolisthesis) and dynamic (e.g. core trunk muscular stabilizers) contributing factors. Similarly, the clinician's consideration of potential contribut ing factors is broad in scope, ranging from the patient's age (and associated degenerative state of her spine) to the stability and mobility of her spine. Her lifestyle. in this case her activity level and pas sion for tennis, are also included, providing a num ber of options with respect to management Hnd an awareness of the patient's personal goals.
PHYSICAL EXAMINAT ION
Francis was evaluated from a biomechanical perspec tive because she was found to be neuro[ogically intact, demonstrating no subjective or objective numbness or sensory deficits and no motor weakness in the [ower extremities. Rellexes were not tested. She presented with a mesomorphic body build and was right handed. Standing
In standing, a hyperlordosis with a palpable step at the L4-L5 segmental level was evident. There was banding of the musculature across the lower lumbar spine and an apparent flattening of the lumbosacral junction. Forward flexion mobility was full range (fin gertips touching toes) and without pain provocation, but the standing forward bending test for the sacro iliac jOint was positive on the right side. The one-legged stork test, another sacroiliac joint screening test, was also posiLive on the right side. Both the forward bend ing test and the one-legged stork test are screening tests for possible involvement of the sacroiliac joint but are non-specific for any particular dysfunction. During the forward bending test. the right posterior superior iliac spine (PSIS) travelled further than the left; with the one-legged stork test on the right side, the right PSIS moved superiorly rather than inferiorly when the patient lifted the right knee up towards the chest. Both of these findings indicated resLTicted mobil ity of the right sacroiliac jOint (Bourdillion et al.. 1992; Greenman, 1996; Isaacs and Bookhout, 2001). Lumbar side bending range of motion appeared to be within normal limits, both symmetrical and painless, w:ith normal pelvic coupling noted dnring side bending to either side. The hip drop test, which is a test for side
bending of the lower lumbar spine. appeared, however. to be restricted on the right side. The test is performed by having the standing patient bend one knee and allow the pelvis to drop. Thus, if the right knee is bent the pelvis drops on the right side, invoking left side bending at L5-S1. The test can also be used to indicate whether or not the sacral base anteriorly nutates on the side of the hip drop. so the test is not speCific for any dysfunc tion but is again a general screening tool (Jsaacs and Bookhout. 2001). Lumbar extension was not pain provocative but was significantly restricted at the lum bosacral junction. with most of the extension move ment appearing to occur in the upper lumbar spine. Sitting
In sitting, the forward bending test appeared to be positive on the right side. With this test, the operator palpates each PSIS with their thumbs and the patient is asked to bend forward. The operator's thumbs follow the PSISs throughout the range of forward bending. In this case. the right PSIS moved superiorly and anteri orly further than the left, indicating resLTicted jOint play motion on the right side. This test is an additional screening test for sacroiliac joint dysfunction but is also non-specific (Bourdillion et aI., 1992; Greenman, 1996; Isaacs and Bookhout. 2001). Palpation of the inferior lateral angle (ILA) of the sacrum with the patient in a fully flexed lumbar position revealed asymmetry with the left ILA posterior and inferior. Positional testing of the lumbar spine in full l1exion revealed no asymmetry of the lTansverse processes from approxin1ate[y L2 to L5, but there was asymmetry at L1. which appeared to be rotated to the right.
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C L IN ICAL REAS O N I N G IN ACTIO N : CASE STUDIES F ROM EXPERT MANUAL THERAPISTS
Active trunk rotation in sitting appeared to be sym metrical bilaterally with no pain provocation. Supine In supine lying, the passive range of motion of the lower extremities revealed a restriction for combined movements of hip flexion, adduction and internal rotation on the right side compared with the left. The patient complained of 'pinching' in the anterior hip and groin on the right side du ring these combined hip movements. Passive straight leg raising was to 80 degrees bil aterally without pain provocation. Palpation of the pubic symphysis revealed an inferior pube on the right side, with significant tenderness to palpation of the right inguinal ligament. Palpation of the lower abdominal quadrant revealed a marked increase in tone and tenderness of the psoas and iliacus muscula ture on the right side. Anterior to posterior translation of the innominates revealed a restriction on the right side compared with the left. There was also a loss of anterior to posterior glide of the right hip joint relative to the left jOint. Ac tive heel slide in supine lying revealed a significant imbalance i n muscle control on the right side versus the left, with Francis unable to maintain a neutral spine on the right side while performing an active right heel slide through full range without the innominate rotating an teriorly. This test is thought to indicate an imbalance between the abdominal and hip flexor musculature, in this case on the right side (Bourdillion et ai., 1992; Greenman. 1996; Isaacs and Bookhout . 2 001). Prone In prone lying, the leg lengths appeared to be symmet rical. as did the ischial tuberosity heights. There was some increase in tension noted on palpation of the right sacrotuberous ligament and there was significant tight ness and tenderness noted on palpation of the right long dorsal sacroiliac ligament. The long dorsal sacroiliac lig ament is thought to become taut with posterior nuta tion of the sacral base (Vleerning et aI., 1996). Palpation of the ILAs of the sacrum revealed the left ILA to be pos terior and inferior. Passive mobility testing of the sacro iliac joints i n prone lying indicated a loss of anterior nutational movement of the right sacral base. Positional testing of the lumbar spine in a prone prop position, where the patient supports their head and chin on their hands while propped up on their elbows, revealed that
t
Fle xi on
Fig. 2.1
Le ft
Ri ght
facet
facet
Pi ct ogra m i llustrati n g an FRS ri ght , a p ositi onal
dia gn osis for a spin al se gment that is held in a fle xed , ri ght rotated and ri ght-side bent p ositi on . This s hows the res p ons e of the transverse p r ocesses (TP) w hen there is an ina bili ty for the l e ft fa cet j oint to cl ose . N ote h ow the TPs appear asy m m etri cal (i.e. r ota ted to t he ri ght in e xtensi on but n ot in flexi on ).
the transverse processes of L5 were asymmetrical. with the right transverse process of L5 being posterior when compared with the left transverse process and the sacral base below. This positional finding is indicative of a loss of the combined movements of extension, left-side bend ing and left rotation at L5-S1, secondary to the inabili ty to close the left facet jOint at L5-S1 (Fig. 2 . 1 ). There was also asymmetry of the transverse processes of 14 found with positional testing in prone on elbows. The left transverse process of L4 appeared to be posterior when compared wHh the right transverse process and L5 below. This positional fmding is indicative of an inabil . i t to close the right facet joint at L4-L5, with a loss of mobility for the combined movements of extension, right-side bending and right rotation. Passive accessory intervertebral mobility testing with unilateral posterior to anterior pressures on the right transverse processes from L1 to Sl produced sig nificant local pain at L4 and Sl. Positional testing and passive accessory intervertebral mobility testing of the thoracolumbar j unction revealed an FRS right (spinal segment that is held in a flexed, right rotated and right-side bent position) at approximately Tll-Tl2 , with a loss of the combined movements of extension, left-side bending and left rotation. Active hip exten sion in prone lying was restricted by over 5 0%, li mited
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2 BACK AND BILATERAL LEG PAIN IN A 63-YEAR-OLD WOMAN
to less than 10 degrees in range bilaterally, with
right. It was felt that this loss of hip extension was
apparent reduction in tone (inhibition) noted on
a consequence of tight hip l1exors (on the right side
palpation of the gluteus maximus, especially on the
greater than the left), in particular the iliopsoas,
REA SONING DISCUS SION AND CLINICAL REA SONING COMMENTARY
o
Please briefly summarize your reasoning at this
The patient also had a positive right hip drop test.
point with respect to your hypotheses regarding
indicative of impaired coupling at L5-S1 with a loss of
the principal sources and contributing factors of
left-side bending at L5-S1 and/or a loss of anterior
these symptoms.
nutational movement of the right sacral base. Palpation of the ILAs. both in forward l1exion and in the prone
• Clinician's answer
extended position , revealed asymmetry. with the left
My initial assessment was that of chronic low back pain and bilateral leg pain initiated by an initial injury
22 years earlier: there was now significant mechanical dysfunction of the lower lumbar facet joints and right sacroiliac joint. along with
LS-Sl grade I spondy lolisthesis and lateral spinal stenosis at LS-Sl. Francis em
presented with marked mechanical dysfunction involv ing the right sacroiliac joint. as well as mechanical dysfunction at L4-LS and LS-Sl. which I [elt was responsible for the referred pain folJowing an L5-S1 distribution in her legs, The patient had significaot hypertoniCity and resultant tightness in the iliopsoas muscuJature bilaterally, greater on the right side than the left. I"vith Limitation 0[' active hip extension mobility as well as inhibition of gluteus maximus musculature,
ILA being posterior and inferior; this is indicative of
either a structural anomaly or a sacroiliac dysfunction. Passive mobility testing of the sacroiliac joints revealed a loss of anterior nutation of the right sacral base. con firming a right sacroiliac joint impairment. The patient also had a positive iliac shear test on the right side. demonstrated by a loss of anteroposterior translation of the right innominate. Palpation of the pubic tubercles revealed an inferior pube on the right with tenderness of the right inguinal ligament. Palpation also revealed significant tightness and tenderness of the long dorsal sacroiliac ligament on the right side versus the left. The loog dorsal sacroiliac ligament became taut and tender in the presence of a posterioriy nutated sacral base (i.e. loss of anterior nutatiooal movement).
especialJy the right. She appeared to have no neuro logical involvement, although she was not assessed for adverse neural tension signs other than wi.th straight leg raising, which was to 80 degrees and pain-free at the initial visit. There also appeared to be limitations in mobility of the right hip, with loss of the combined movements of hip flexion, adduction and internal rota tion, possibly secondary to lumbar and pelvic dysfunc tion or secondary to a tight posterior right hip capsule.
D
• Clinical reasoning commentary What should be evident throughout the clinician's physical examination and reasoning is the specilk nature of his hypothesis testing. That is. hypothe ses regarding possible sources and contributing factors formulated during the subjective examina tion are specifically tested through the phYSical examination. The physical impairments identified include impairments of spinal. sacroiliac and hip
Please elaborate on your analysis of the
joint mobility, soft tissue/muscle shortening, and
sacroiliac joint impairment.
increased muscle tone and poor motor control. Nevertheless. the character of the clinician's sum
Clinician's answer
mary of I1ndings rellects an open mind. Identified
I felt that sacroiliac jOint impairment was evidenced by
impairments are presented as an 'initial assess
several key t1ndings during the screening examination.
ment', consistent with the subjective presentation.
The patient had a positive forward bending test on
The impairments identilied represent treatment
the right side. both in standing and in sitting. and a
options that. through intervention and reassess
positive one-legged stork test on the right side as well.
ment, will ultimately establish their relevance,
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C LI N I C A L REASO N I N G IN ACTION : CASE STUD I E S F ROM EXPERT MANUAL T H E RAPISTS
r explained my clinical findings to Francis and my rec
ommendations for treatment. She initially understood her treating diagnosis to be mechanical low back pain with a n L 5-S 1 spondylolisthesis and lateral spinal stenosis a t L 5 -Sl. I did not feel there were any con traindications to physical therapy intervention and so she was scheduled to see me initially for eight treat ment sessions over a 30-day period. Francis and I jointly agreed her goals for treatment would be for her to be able to play tennis without provoking back or leg pain, and to be able to control her symptoms with a home exercise programme and with decreased usage of her pain medication (nabumetone). We also set another functional goal for her, which was to be able to tolerate standing on her feet for prolonged periods or time, up to 1 to 2 hours. without leg pain. such as when window shopping. washing the dishes and hoov ering. I anticipated that these functional goals would take approximately 1 month to ach ieve and that the prognosis for improvement and accomplishment of these goals was good to excellent. Following the evaluation, treatment was initiated and consisted of muscle energy tech niq ues to treat an FRS right at L 5 -S1 and an FRS left at L4-L 5 . so as to restore extension mobility from L4 to Sl. For both of lhese techniques. Francis was treated ly ing on her side. specifically localizing forces first to L5-S1 and then to L4-L 5, with extension from above down and from below up combined with the appropriate side bending and rotation (Fig. 2 . 2). Francis was asked speciftcally to work primarily with an active side-bending effort using the leg as a long lever, followed by post-isometric relax ation to increase side bending and extension of the spinal segment. I directly mobilized the sacroiliac joint u tilizing a technique to treat a unilateral posterioriy
Fig. 2.2
Mus cle ener gy te chnique for corre ctio n of a FRS
ri ght (s p i n al se gme nt that is hel d in a fl e xed , right rotated and ri ght-s ide be nt position ) at LS-S 1 .
nutated sacrum on the right to improve anterior nutation of the right sacral base (BourdiJJion et al . . 1 9 92; Green man. 1 9 96; Isaacs and Bookhout. 200l). The inferior pube on the light side was also treated with muscle energy techniques. by resisting active hip extension and then upon relaxation correcting the inferior pube by pressing the ischial tuberosity in a superior and medial direction. The reader is referred to Greenman ( 1 9 96) and Isaacs and Bookhout (200 1 ) for further detail of these techniques. Francis received deep soft tissue mobilization to the iliopsoas muscula tu re. especially on the right side, followed by instruc tion in kneeling hip nexor stretching and prone transversus abdominis retraining to practise at home. Specifically, I attempted to re-educate and balance the musculature on the right side of the pelvis, based upon her initial inability to perform a supine heel slide on the right side without anteriorly rotating the innominate.
R EASONING DISCUSSION AND CLINICAL R EASONING COMM ENTARY
D
What were the key features in this presentation that you recognized
as
indicating a good prognosis!
• Clinician's answer I felt Francis had a good prognosis based upon the fact
that she had a specific goal in mind for treatment (Le. returning to playing tennis). She also had good gen eral health habits, appeared to have no psychosocial
factors. and she appeared to have speci11c mechanical jOint restrictions that I felt were d irectly related to her symptoms and clinical presentation .
D
Mutually agreed formal goal setting is clearly a key feature of your management. Could you briefly hi ghlight your views on the significance of mutual goal setting!
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2 BACK AND BILATERAL LEG PAIN IN A 63-YEAR-OLD WOMAN
• Clinician's answer I place considerable value on mutual goal setting to establish good communication between myself and the patient. I believe this is an essen tial component of the first initial visit. to make sure that the patient and I have the same expectations to measure the effective ness of treatment. If mutual goal setting is not done at the onset of treatment, the patient may have a different goal from that of the therapist. with the patient and therapist measuring the success or failure of treatment from two different perspectives (Le. the patient's goal is total pain relief while the therapist's goal is increased tolerance for sitting, walkin g, other activities in daily living). This can create a sense of disappointment over the course of treatment if the patient feels his or her needs are not being met despite 'objective' improvement noted by the treating therapist.
Clinical reasoning commentary
key dimension of clinical reasoning evident in the clinician's philosophy of management is his collabo rative approach with the patient. As discllssed in Chapter 1. patients begin their encounter with a man ual therapist with their own ideas of and feelings about the nature of their problems and the manage ment they want. as shaped by personal experiences and advice from medical practitioners. family and A
On a subsequent visit. latissimlls dorsi sel f-stretching was added as Francis appeared to be Significantly tight on the right side. The latissimus dorsi was found to be tight by assessing bilateral shoulder flexion in supine lying with the lumbar lordosis eliminated. The latissimus dorsi was s tTetched using the technique described by Evjenth (Evjenth and Hamberg. 1 984) to decrease stress at the lumbosacral j u nction. After the fifth visit, and approximately 2 weeks into treatment, Francis reported she was able to play tennis without leg pain and had noted a substantial diminution in her need for pain medication. decreasing her dosage
Fig. 2.3
Muscle energy technique for stretching the hip
flexors on the left side.
friends. For some patients. their meaning perspectives (understanding/beliefs. aUiLudcs. emotions and expectations) are distorted and counterproductive to their recovery. Successful patient management is opti mized when therapists attend to the patient's perspec tive and include the patient in the decision making. The clinician's explanation of I1ndings and philoso phy of involving the patient in setting treatment goals exemplify this collaborative approach to reasoning.
by over half. The hips were then treated, utilizing muscle energy techniques to lengthen the iliopsoas. tensor fascia latae and hip external rotator muscula ture, These muscle groups were stretched in prone lying with the opposite leg off the end of the table and supported on the floor (Fig. 2 . 3 ) . In addition. the hips were mobilized in a posterior to anterior direction to improve both active and passive hip extension mobil ity. Piriformis self-stretching in supine lying was added to her home exercise programme. along with gluteus maximus retraining while maintaining a neutral lumbar spine with transversus abdominis activation.
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CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
REA SONING DISCUS SION AND CLINICAL REA SONING COMMENTA RY Please discuss briefly your philosophy of reassessment, providing examples of how in this case reassessment was used to determine the
provoking, in this case rotation in standing (e.g. as in playing tennis).
effect of any given treatment procedure.
Clinical reasoning commentary
• Clinician's answer At each visit. I reassessed the major clinical findings, which included mobility for extension at L4-L5 and L5-S l, as well as mobility of the right sacroiliac j oint. I also monitored recruitment of the right gluteus maximus and tranversus abdominis musculature and I reassessed the right hip for combined movements of flexion, adduction a nd internal rotation. My expect ation was to find improvements in jOint mobility at L4-L5 and L5-S l , as weI! as mobi lity of the right hip and right sacroili�c joint from one treatment session to the next. I attempted to correlate improvements in joint mobility with improvements in function a l performance by asking t h e patient to show active movement (Le. extend the h i p, recheck the forward bending and one-legged stork tests, and recheck the right hip drop test). I feel it is important to show the patient (as well as to remind the patient) of how their original findings have changed , since often a change in movement/mobility, both actively and passively, occurs before the patient's symptoms improve, espe Cially in patients with chronic pain.
D
You have described attempting to re-educate the balance of this patient's lumbopelvic musculature, highlighting examples of training in supine and prone lying. Was it necessary for the patient to progress this retraining to other positions!
• Clinician's answer Although not directly discussed in this case, I gener aJly progress patients from non-weight-bearing exercises to weight-bearing exercises and activities, incorporating the patient's exercise programme into functional activities and activities of daily living. I believe this is especially important in retraining muscular control , especially retraining for activities that previously were reported by the patient as pain
For skilled manual therapists, reassessment is sec ond nature. However, it is important to recognize reassessment as a form of hypothesis testing by which the therapist's understanding of the problem and the person is either supported or not supported. and management continued or altered accordingly. The breadth and specificity of reassessmcnt will vary according to the nature of the problem alld the pain mechanism j udged to be dominant. In any case. care is needed when hypotheses regarding t he 'source' or pathology are tested through reassessment. Clearly an improvement. in mobility. muscle control or pain response does not conlirm a source or pathology. For t hat. more sophisticated assessment/reasscssment through advunced imaging procedures. electromyo graphy or other medical investigations arc needcd, many of which themselves have poor predictive validity. We encourage therapists to hypothesize about specilk structu re/tissue sources and to con sider the nature of the pathology, as these deli berations will assist therapists' search for a better wlderstanding of the relationship between palllol ogy. pain and physicul impairment. However, to avoid misleading yourself that you have c1Tected a change in the pathology or structure of a specific tis sue, it is better to view your treatments. as the clini cian has here. as being directed t oward a specific impairment (physical or psychological) in order to establish the relevance of the identified impairment to the patient's presentat ion . Encouraging patient understanding. which may require modil1cation to their pre-existing per spectives, is an ongoing feature of manual t herapy management. Even subtle strategies, as the clini cian has alluded to here when pointing out to the patient changes in the impairment. contribute to improved patient understanding. As discussed in Chapter 1, improved understanding fosters greater self-efllcacy/responsibility and patient participa tion in management.
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2 BAC K A N D BI LATERAL LE G PAIN IN A 63-YEA R-OLD WO MAN
Outcome Francis received 11 treatments over the course of 2 months. When seen for her last appointment. she reported that she was doing extremely well. was no longer taking any pain medication. and no tably had no leg pain complaints even after playing tennis for 1. 5 hours. She had intermittent mild low back pain that she reported was not limiting her activities of daily l iving at all. Francis felt that her exercise pro gramme gave her significant control of her symp toms. and she now rated her low back pain as 2110 compared with 4/10 initially. Her mechanical find ings were reassessed and compared with the i nitial evaluation. She had regained full and pain-free range of motion of the right hip for f1exion. adduction and
internal rotation and showed significant improve ment in anterior nutational movement of the right sacroiliac joint. Positional and passive mobility test ing of the l umbar spine revealed improved mobili.ty at L4-LS. with only slight restriction on the right side at LS, which was treated on her last visit with unilateral posterior to anterior grade IV pressures (Maitlan d , 19 86) . She now was better able t o recruit t h e gluteus maximus on the right side d uring active right hip extension i n prone lying. and her hip extension range of motion had notably improved, with the ability to extend the hip 10-15 degrees from the prone lying position bilaterally. Francis was discharged from physical therapy 2 months after initiating treatment and instructed to call should she have any further questions or problems in the future.
References Bourdillon. J,F.. Day. E.A. and Bookhout.
Greenman,
PE. (1996). Principles of
M.R. (1992). Spinal Manipulation.
Manual Medicine. 2nd edn.
5th edn. Oxford: Butterworlh
Baltimore. MD: Williams &
Heinemann.
Wilkins.
E\ljenth. O. and Hamberg. J. (1984).
Isaacs.
Maitland. G.D. (1986). Vertebral Manipulation. 5th edn. London: Butterworth. Vleeming.
E.R. aod Bookhout. M.R. (2001).
Hmnmudughlu. B. et al. (1996). The
Muscle Stretching ami Manual
Bourdilloo's Spinal Manipulation.
function of the long dorsal sacroiliac
Therapy. A Clinical Manual. Vol. 1.
6th edn. Woburn. MA:
ligament. its implication for understand
Alfta. Sweden: Alfta Rehab.
Bu tterworth-Heinemann.
ing low back pain. Spine. 21.556-562.
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Ongoing low back, leg and thorax trou bles, with tennis elbow and headache David Butler
�
SUBJECTIVE EXAMINATION
During my c l inical career, I can recall four particular patients who stand out as prod ucing significant changes i n my understanding of clinical presenta tions and my professional direction. The patient described here, with ongoing low back, leg and thorax troubles, plus tennis elbow and headache, is the most recent. Ru by. a 5 2 -year-old sligh tly overweight European woman with a sparkle in her eyes was referred via a physicia n to ascertain the value of continuing physio therapy treatment for o ngoing back pain. I noticed immediately that she had little trouble getting up the two llights of stairs in our practice. and when I intro duced myself I had the feeling that s he was not too sure about bei ng there. I asked her an opening question, ' What do you feel is your main problem ? ' , and then she began to talk. I did not h ave to ask many questions, she only stopped when she wanted to ask a question, and sometimes I j ust had to nod for her to continue telling her story. I have attempted to group Ruby's story i nto traditional categories. although the story unfolded as s he wanted to tell it. Ruby said she was 'inj ured' at work 14 months ago. She was a s hop assistant. 'Something definitely went in my low back ' . she said, ' when I was l ifting bundles of clothes onto shelves, nothing much differ ent from what I do normally, but perhaps the bund les were larger.' Prior to this there were just the ' usual aches and pains everyone gets, but I was fit and could
do anything'. Ruby admitted that work was 'a bit stressy' at the time because she worked in a large department store in which there had been some downsizing, a nd a few of her colleagues around her age had lost their j obs. She was working three half days a week and said that she was j ust managi ng, with not much time for anything else. Her goal was to return to her original three fu l l days of work per week. I asked Ruby to show me where she felt her prob lems were (Fig. 3 .1). She described a wide area of dis comfort in her lumbar spine and she ran her hand down her right leg in what looked like a combination of the L4 and L5 derma tomes (,I have done this so many time I think I have rubbed it 01T' , she stated ) . There. was a small area j ust rig ht of her lumbosacral segment that she said was particul arly tender and which she encouraged me to touc h. In addition her whole right foot 'didn't feel right', although there was no paraesthesia or a naesthesia. She had had some diffuse mid-thoracic pain for at least 6 months. 'My shoulder blades make cracking noises too', she added. In addition. Ruby complained of left lateral elbow pain present for 2 months, which she said had been 'dismissed as tennis elbow'. She commented, 'You are the first person to seem interested in my elbow. Most people don' t want to know, yet sometimes I think that the elbow can be as bad as the low back.' There were also some headaches and neck pain, but she felt that her lower back was the 'core problem'.
36
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3 O N G OIN G LOW BACK, LEG AND TH ORAX TROUBLES, WITH T E N N I S E L BOW AND HEADAC HE
Occasional
--l---- headache �f---- Occasional neck pain
�
_Sc----i----f'=- "Cracking" "OMen upset"
�
"Tennis elbow"
.." � down leg if back is bad"
not right"
(a) Fig. 3.1
(b)
Body chart il l us tratin g the patient's symp toms.
R EASONING DISCUSSION AND CLINICA L R ,E ASONING COMMENTARY
D
What were your thoughts at this early stage!
• Clinician's answer My first thought was that Ruby had a pain state from minimal trauma and that there had been plenty of time for the inj ury to heal. Immediately my thoughts were directed at the possible processes that could be contribu ting to ongoing sensitivity. My i nitial thoughts are summarized in the reason i ng categories below.
Pathobiological mechanisms
Pathobiological mechanisms are likely to involve mul tiple processes. Although tissues have had time to heal, they are likely to be unhealthy and there may be significan t physical impairment. To explain her pain state, there are hints of peripheraJ neurogenic (e.g. area of leg pain) and central mechanisms (e.g. spread and
persistence of symptoms) . There is surely nociceptive (tissue-based) pai n , perhaps from combinations of deconditioning, acidosis, neurogenic inflammation, and persistent physical dysfunction. Upregulated nervous systems are likely to involve perturbed out put and homeostatic systems, such as the endocrine, autonomic and immune systems. Sources
there is impairment with peripheral neurogenic mechanisms, then a reasoned source is the L4 or L5 nerve root. If there is nociceptive impairment. then any of the mobile tissues may potentially be unhealthy and could perhaps be iden tified on physical examina tion. The anatomical sources of the central seflsitivity are impossible to identify, but descending endogenous pain control pathways, the dorsal horn and multiple brain areas, including sensory, motor, attention, mem ory and limbic systems, are likely to be involved.
If
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CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
II
Prognosis
On the 'good' side is her disposition, as indicated by her comment 'its been there only 1 3 months' . Perhaps some obstacles to recovery are work difficulties and the widespread and worsening nature of her symp toms. r was encouraged at this stage.
Also. you state that she did not have any paraesthesia/anaesthesia. suggesting that you screened for this particular symptom. Could you highlight what sorts of screening questions you would use when the patient does not spontaneously volunteer the information?
Clinician's answer Management
Management strategies are likely to involve education regarding the nature of the inj ury, reasons for pain maintenance and unnecessary fears related to move ment. It may involve pacing activities in relation to sensitivity and devising activities that present learnt painfu l movements to the brain in non-painful ways. It will probably involve active and passive treatment of relevant physical impairments. S he will also need to get fitter.
Contributing factors
There are already hints of work-related stress. This lady has quite a diffuse array of symptoms. Can you comment on why you would want to know about all her complaints rather than just her main problem?
• Clinician's answer The biological processes behi nd all the complaints are l i kely to be the same, but all complaints are needed for a working diagnosis. For example, knowledge of the elbow pain could support a hypothesis of central sen sitization or a hypothesis of a generalized inl1amma tory disorder, or perhaps a local tissue-based pain state from inappropriate use of the part. The big picture is necessary for therapy. For example, it may be the elbow pain that prevents particular activities which may help the low back. Ruby's main problem(s) may weU vary during therapy. This appears to be a clinical feature of central sensitization. If explanation is hypothesized as a key manage ment tool, she will want all symptoms and features explained. It is important that Ruby knows that the elbow pain, the headaches and the cracking in the thorax are not new problems, but that they are likely to be an expression of one process.
There are many different questions that may need to be asked if the patient is reticent to volunteer infor mation. For example, with respect to other types of symptoms, it may be necessary to ask about pins and needles or whether there are a ny areas that are numb. Clinicians will need to ensure that the patient's comprehension of ' numb' is the same as theirs. This question is related to the sensory aspects of periphera l neurogenic/central contributions. Asking whether there are areas that 'don't feel the same as before the injury' or which 'don' t feel the same as the other side' can a lso be revealing. Other screening questions. seeking hints of autonomic and motor involvement, include changes in sweating, skin health and feelings of weakness.
• Clinical reasoning commentary The breadth and openness of the clinician's ' work ing diagnosis' is evident. As suggested in Chapter 1, a manual therapy diagnosis should be one that captures the clinician's understanding of the per son (Le. narrative reasoning) and the person's problem(s). This should include, as provided here, the clinician's j udgment regarding each of the hypothesis categories. It is not sufficient simply to identify structures involved, as this alone does not provide sufficient information to understand the problem and its effect on the patient. or to j ustify the course of management chosen. The manual therapy diagnosis must include a hierarchy of con siderations. including the activity and participa tion capabilities/restrictions, the pathobiological mechanisms, patient perceptions of their experi ence (i.e. psychosocial issues ) , specific impairments identified and their associated hypothesized sources, and contributing factors. The clinician's narrative and collaborative rea soning is also evident in this patient-centred inter view where he encourages the patient: to tell 'her story' in the way 'she wanted to tell it ' . This aspect
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3 O N GO I N G LOW BAC K, LE G A N D T H O RAX T RO U BLES, WITH T E N N IS ElBOW A N D H EADAC H E
to
beliefs, desires, motivations, emotions). the basis of
understand the patient as a person. including their
their perspective and how the problem i s affecting
perspective of the problem ( e.g. understanding.
their life.
of clinicians'
reasoning rcquircs
attempting
Symptom pattern
no sport. although she had tried tennis with painful
Ruby felt that there was always some low back pain. although it varied. The leg pain came o n when the back pain increased, or i f she did a lot of bending. Her few hours at work usua lly brought i t on. This involved some light lifting and general sales. The pains were genera l ly activity related. gardening for instance, but not necessarily. She mentioned that she 'could be watching television and the back and leg might hurt' . Further questioning revealed that sitting was perhaps an aggravating factor and 'staying sti ll could also bring it on' . If she was sitting or doing paperwork while standing at work, she would get uncomfortable and the leg pain would manifest. There were no par ticular movements that aggravated her symptoms and she said that her spine felt a ' bi t stiff ' . There were no autonomic or vascular type symptoms. ' [ j ust don't understand it and no-one else seems to either', she comp lained . The only things that would ease the pain were forgetting about it, time. or sometimes a few gin and tonics would 'take the edge off it or make me forget it'. Listening to music,
'especially Barry Manilow ' ,
would also help. but 'none o f that heavy rock stuff that my son listens to though'. She was smiling. [ asked her
results (prior to the accident she played vetera n's tournament tenni s , golf occasionally and enj oyed working for hours in the garden). Ruby had no specific activity goals but im mediately said that she would l i ke to spend more time in the garden as ' i t ' s crying out for attention ' . S h e s a i d spontaneously, 'I feel a bit caged in; I don't know wh ich direction to take. Sometimes
I want to fight the pain, but [ know
from experience that it won ' t do me any good. My husband avoids the garden and my son is too busy study ing.' When pains came on she usually stopped, although she said on some days, '[ j ust try and fo rget it and march straight thoug h ' . She wanted to return to 'work, not fu ll-time but about 30 hours per week, j u st the same as before.
I asked her whether she had developed any new movement habits after the inju ry. She thought for a moment and said, 'that's interesting ' . She explained that she now bent to the right to pick things up a nd she would squat rather than bend to reach the Ooor.
Thoughts, beliefs and feelings about the problem
about her family. Her husband of many years was
When
supportive and believed she should keep active, and her
was, there was silence for a few long seconds. 'Not
I asked Ruby what her concept of the problem
son was at un iversity and was happy. Her spouse was
sure ' , she said , 'but there is something wrong or out in
healthy, although his father had bad back pain, and he
my back, I know that, maybe a nerve or a disc or some
had always believed in the value of exerc ise.
thing. I don't know why it seems to be spreading and
She slept well. She fu rther commented that 'every
I am getting these new problems. I was worried it was
one asks me that and they seem surprised when I
a horrible arthritis l i ke my auntie had, so I was pleased
reply that sleep isn ' t a problem and once
I am in bed
[ usually sleep very well ' .
about the blood test (negative, see below). Someone mentioned fibromyalgia once, but not again. The physiotherapist says I have stiff joints and some neural tension. No,
Activity level s and goals
I don ' t really know what has happened to
me and [ cannot really understand why it does not go
Ruby ' s activity levels had altered considerably com
away. It would be easier i f [ had a broken bone.
pared vvith pre-injury levels. She adored gardening
that heals and you can show the plaster cast to people.'
I know
but was frightened about damaging her back a ny
Ruby said she had hope that it could be fixed and
further. She had been warned to stop gardening after
she thought it would need some exerc ises and per
the injury and now she 'just potters arou nd' for about
haps something 'put back in place ' . She wasn ' t going
hal f an hour. Wa lking was restricted to a few times
to give up and thought that there may be surgery that
around the block or about 30 minutes. She played
could fix it. The fact that it had been going o n for over
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CLI N I CAL REAS O N I N G IN ACT I O N : CAS E STUDIES FRO M EXPERT MAN UAL THERAPISTS
a year was a big worry, and she added, 'J know the story on back problems i sn't too good' . Spontaneously she said, 'J really want to know what is happening in there'. I asked her what it was mce when she was angry or stressed and she immediately, almost resigned ly,
replied that i t was worse, especially if there was leg pain. J told her that that "vas the case for most pains. She said that she didn' t like going out now, and added 'My husband must be getting sick of it-J am not the happy bouncy person I once was' .
� R EASONING DISCUSSION AND CLINICAL R EASONING I J COMMENTARY Have any patte r ns (for example, related to pain mechanisms, contr i buting factors or prognosis) emerged for you from this
appropriate amount of movement in relation to her sensitivity.
II
additional information regarding the sym ptom pattern?
Could you comme nt on your im pressions/ hypotheses regarding Ruby's cogni tive/affective status (i.e. her perceptions of her experience),
• Clinician's answer
specifically w i th respect to any ' yellow flags' and
While a mechanical pattern has emerged it is not a clear pattern with a closely linked stimulus/response feature. It suggests combinations of primary hyper algesia (tissue based) and secondary hypera l gesia (central nervous system based ) . The fact that sitting and stand ing at work evoked pain suggests that con tributing factors such as work-related ergonomic fea tures and job stress may need addressing. Anecdotally. patients with hypothesized central sensitivity can sometimes sleep remarkably well.
What is your i n te r pretation of her 'easing factors' (forgetting about the pain , time,
posi tive/negative factors i n her prognosis for con tinued pai n , disability and l i kelihood of returni n g to wor k ?
• Clinician's answer The key yellow flags here are: a poor explanatory model that has included mul tiple explanations and the concept of ongoing tissue damage • the fact that pain is controlling her • her fear of activity-related damage to a structure • withdrawal from social interaction.
•
However it was not all bad. For example, Ruby still had hope, was seeking some self-help via explanation, had a supportive family and appeared likely to accept an active approach to rehabilitation.
alcohol and music) ?
• Clinician's answer These are frequent characteristics of central sensi tization. A small amount of alcohol may be a relaxant through central enhancement of the serotonergic system. The key thing i s that these features can be used as part of explaining about what appears to be central sensitivity. It may help to demonstrate to her that focussing on the pain may make it worse, how distractive techniques could be useful. and how she does have some control over the problem. To help to explain increased sensitivity, one could use the example of the more mellow Barry Manilow music being more acceptable than the heavy rock music. This observation could be related to get her to do an
Clinical reasoning commentary
The concept of hypothesis categories has been put forward in this book as a means by which thera pists can organize their knowledge and focus on clinical thinking. However, reasoning regarding the various categories of hypotheses docs not occur in any set sequence. Reither, clinica l reason ing is a dynamic process and j udgments regarding the different hypotheSis categories are interlinked. For example, here the clinician describes how the patient 's . report of 'easing factors' was not only
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3 ONGOING LOW BACK, LEG AND THORAX TROUBLES, WITH TENNIS ELBOW AND HEADAC H E
supportive of the pal.hobiologkal mechanism o f central sensitivity. b u l also h ow L h i s same informa tion Illay also be used i n the management strategy of ex plana lion/ educal ion. The key aspect of c l inical reasoning evident in t he clinician's answer regarding Ruby's cognitivc/alfectivc slates is h is attention to both sllpporting und negat ing clues/evidence. While clinical reasoning has a scient i llc basis. it is not a hard science. Many patient
�
iden tify precautions
.�I)�(r�!!ltI �ags .
A radiograph taken 3 weeks arter the injury showed some degeneration of the lower lumbar spine, most marked at t h e L4-LS and LS-Sl levels, and a little worse on the right side. There was minimal encroach ment of Lbe intervertebral foramina at these levels. A more recent radiograph was similar. Ruby had been told that there was 'degeneration in the l umbar spine ' . A complete blood test revealed no abnormalities. S h e had been told t h at they were checking for arthritis a n d it had been explained t h a t t h i s was normal . A recent computed tomography (CT) scan was also reported as showing 'degeneration in the lower lumbar spi ne; no nerve compression ' . With these resu l ts plus my
presentations are multifactorial and filled with con flicting evidence. This req uires care to avoid prema t ure tlnal judgments and bias, where one or two key features are attended to and cont1icting evidence or competing hypotheses are neglected. This is demon strated i n the clinician's predict ive reasoning with respect to psychosocial risk factors for chronicity. or yellow flags. where he has idenlitled both supporting anu negating evidence.
subjective interview. I excluded serious pathology and I again reassured Ruby that 'it sounds promising ' . Ruby had tried a 'cocktail o f drugs' over the past year but was currently not taking any med ication. S he stated that she ' would rather h ave the pain, than enjoy the little benefit they give, and having to worry about what drugs do to my kidneys' . Bladder and bowel function she said ' were OK' . although there was sometimes pain with her bowel movements. Straining could evoke back and leg pain. S he felt that her stomach was much more sensitive than before the inj ury, when she could eat anything. Other than the pain, Ruby felt in reasonable health , a lthough she admitted to being unfit. She was a non-smoker and there was no impend ing legal action, 'I have practically given up sex ' , she added .
� REA SONING DI SCU S SION AND CLINICAL REA SONING I J COMMENTARY -
D
• Clinician's answer
What were your thoughts regarding this information?
Clinician's answer
I thought that there was no need to refer her back for further medical assessment and I felt I coul d reassure her that there was no serious u nderlying disease process. I also thou ght it might be worthwhile getting her doctor to reinforce this. I n addition. I fel t more positive considering her attitude regard ing drugs and the lack of impending legal action.
D
Did you think the difficulties with her bowels and the increased sensitivity of her stomach warranted any concern and follow-up investigation?
No. My reasoning was that bowel-related pain was mechanical and perhaps rel ated to ongoing nerve root sensitivity as it increased leg pain . At this stage, increased stomach sensitivity could be seen as part of a central sensitivity.
• Clinical
reasoning commentary
Screening questions serve the purpose of identily ing whether other types of symptoms. aggravating or easing factors and. as used here. specine red flags (i.e. symptoms and signs requiring emer gency referral to a spinal surgeon and signs and
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CLINICAL REASO N IN G IN ACTI O N : CASE STUDIES F RO M EXPERT MAN UAL THERAPISTS
symptoms suggesting possible serious pathology) are present that the patient may not have sponta neously volunteered. Yellow flags (i.e. psychosocial risk factors of chronicity ) . including blue nags (patient's perception of work) and black flags
�
(actual work characteristics). and symptoms and signs suggestive of a non-musculoskeletal disorder masquerading as musculoskeletal dysfunction should also be routinely screened.
PH YSICAL EXAMINAT ION
Active movements
looked at Ruby 's general posture and noted a kyphotic thorax and a slight forward head posture. In general. her back looked strong with well-developed musculature. I thought how chronic pain was such that it could be masked and a hidden phenomenon in society. I\m I looking i n the right place ?' I thought. She coul.d squat, and there were no great abnormal ities detected when r observed her waJl<ing. Balance on either leg was not good, especially the right leg. which she could only balance on for a couple of seconds. Ruby's active lumbar movements seemed reason able. Lumbar extension looked stiff, particularly in the low lu mbar region. and I noted that during exten sion she sh ifted to the left. away from the painful lower limb. The movement was restricted but no pain was produced. Lateral l1ex ion to the right seemed a bit more restricted than to the left. particu larly in the lower regions. On lumbar flexion, there was a pulling sensation and some diffuse pain across her lumbar spine and buttocks, although she could nearly touch the 11 0or. These symptoms increased when I carefully added cervical flexion. I looked at thoracic rotation only. There was some stiffness and a little mechanical hyperalgesia in the thorax on rotation to the left. In addition, there was also a cramping feeling in the thorax. Ruby could lift her arms above her head easily and without discom fort. 'That crackling noise should go when you are moving better' . I ex plained. During cerv ical spine retraction, the thoracic pains were provoked. I
Passive movements I performed a quick palpation examination. There was no excessive warmth in tl1e tissues and I palpated the thorax and lumbar spines both cen trally and u ni laterally. Ruby was byperalgesic all along her thorax, especially a t the mid-thorax where it felt particularly
stiff to posteroan terior passive accessory in terverte bral movements. The l umbar spine was also hyper algesic, particularly the lower lu mbar region and espec ially on the right side. although I could not detect any localized stiffness. There was also multiple area tenderness when I palpated over the sacrum. Neurodynamic testing revealed: Straight leg raise (SLR) of the left leg was 80 degrees with a pulling feeling behind the knee. • Right SLR was abou t 6 0 degrees with some pulling sensation behind the knee and a 'dragging feeling' in the l umbar spine. • Passive neck flexion in supine lying produced a very slight pulling feeling in the lu mbar spine and a mid-thoracic pain at end or range. • The slump test was performed actively with some guidance. On in itial slump 'nothing' was felt. The addition of neck l1ex ion 'pulled ' in the thorax. and left knee extension at minus 1 0 degrees 'pulled ' in the mid-hamstring area. Right knee extension was about minus 20 degrees and evoked symptoms in the back and thorax. There was also a 'vague numbish' feeling in the right foot. All of these symptoms were eased when the cervical spine was extended. even with j ust upper cervical extension . •
Neurological examination
While standing. heel walking revealed some right sided anld e dorsillexor weakness, and heel raising also showed some slight right-sided weakness. For both these quick tests, weakness was only evident after five or six repetitions. 'Is it safe to do this?' she asked. 'No problems. you are doing wel l ' , I replied . Her quadriceps rel1exes were equal. although somewhat hyper-rellexic. The ankle jerks appeared equal and normal. There was a slight decrease in strength in all right-Sided muscle groups below L2 . I thought that the L4 muscle test (ankle dorSiflexion)
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3 ONGOING LOW BACK. LEG AND T HORAX TROUBLES, WITH TENNI S ELBOW AND HEADACHE
stood out as the weakest. The tendon oC the contracted right tibialis anterior muscle was softer to palpation than on the left side. There was hypersensitivity in her posterior right leg to a cursory light touch exam ination, although this could not be localized to a dermatome. Mild, bilaterally equal ankle clonus was evident. I told her that her ' nerves were firing wel l ' . Pinprick was n o t performed . Ruby said that she was a little sore in the back after the examination. I reassured her that this was natural. Initial assessment
The above subjective and physical examination had taken me about 45 minutes. [ told Ruby that I would need to continue the examination and get some more details next time. As she left, I told her that I wanted to achieve four things for her within the next few visits: 1.
Explain what I thought was wrong as far as the most current scientilk understanding of spinal pain would allow ( th is would include why the problem was stUI persisting):
Clarify how long it would take to improve and what improvements were possible: 3 , Present all the options of what she could do for it. 4. Advise her what physiotherapy could do for the problem. I said that I was sure I could help her and s how her how to manage her problem. 2.
She looked at me somewhat quizzically, said ' thanks' and left. I wasn't sure whether she was going to come back. During the examination, I made notes on what I thought I should specifically attempt to explain to her. These i ncluded: • • • • • • • •
why the problem had not gone the spread of pain what the tennis elbow meant the cracking noise under the scapula why pain came on for no reason why there had been various explanations for the problem why moods affected the pains the radiograph findings.
REASONING DI SCU S SION AND CLINICAL REA SONING COMMENTARY Please comment on your thoughts regarding
II
Many patients expect to receive some 'hands-on'
whether your findings on the phYSical
treatment at their first appointment. Could
examination fitted with your thoughts following
you briefly discuss your views on this and the
the subjective examination, with respect to
risk that the patient might not return, as you
pain mechanisms and sources associated with
commented above might be the case with
her symptoms and impairments.
this lady.
• Clinician's answer
• Clinician's answer
Yes they IItted. Ruby may have had better general movements than [ thought she would, but this i s understandable with a hypothesis of central sensitiv ity. I believe that because I spent a significant amount of time with the subjective evaluation and let her tell her whole story a clinical environment was created which allowed her to move reasonably well. There is clinical evidence of peripheral tissue involve ment (e.g. neurological findings, area of symptoms) and a pattern that. on the basis of modern neurobiology in particular, could be argued as central sensitivity.
[ believe that it is a myth that this kind of patient desires hands-on treatment at their first visit. Often many patients have had failed hands-on treatment. In this particular case, my reasoned j udgment was that her desire for information and support was much stronger than for an instant ' fIX it'. If a subjec tive enquiry reveals that a patient really wants mobilization, traction or ultrasound, then it may be worth giving it to them, so long as the therapist and patient do not fal l into the trap of bel ieving that this is the l ilcely sale and necessary treatment.
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The danger is that the delivery of such techniques, with possible short-term beneficial results from treat ment, may reinforce the notion that. tissue damage is the only cause. The patient has to see the place of physical findings in the big picture. as much as clinicians must. Most patients want a good physical eval uation. There is plenty of usel'ul therapeutic touch in the physical exami nation. Perhaps we should rea l i se that the physical examination i s in fact t.reatment. and that the patient is consciously and subconsciously learning from your physical examination. In retrospect. in this particular patient, my fears 0(" her not returning reflected my own insecurities. not hers.
• Appointment 2 Ruby arrived early for the second appointment. She said that she felt quite tired after the previous exam ination. I quickly went over things t.hat. I had forgot ten to ask in the first examination or which need ed confirmation. S he h ad received previous treatments. The thorax and l umbar spine b a d been manipulated many times by various professionals. This would usually give rel ief. though not always. Hydrotherapy was tried but did not help. She had tried various exercises but found ' when I concentrate on the back, it. sometimes gets worse afterwards'. I rechecked the active movements ( no cha nge i n pattern observed at first appointmen t) , performed a Babinski examination (negative) and performed a closer palpation or her l u mbar spine. The left L4-L5 area was the most tender, although the same general ized tenderness was evident. Both SLRs were similar to Day 1. perhaps a little better. With the right ankle dorsil1exed and inverted, and then the leg raised, there was significantly more hamstring and back pain than on the other side. r checked the slump test in long-sitting. Pain was evoked in the m id-thora x in this position and could be eased by cervical extension a nd by both left and right knee flexion. I performed a left upper l imb neurodynamic test (Butler. 2000) for the radial nerve. There was a l ittle
Clinical reasoning commentary
As the clinician pOi l l ts out. hands-oll treat lllcnt is not essential at the IIrst appointment. Munagemcilt is. however. He right·ly argues that a thorough examin ation should be seen as part or management and t hat explanat ion/education is an i m port an t . sometimes lhe most important. aspec t of our management. For some patients with complex presentat.ions such as this lady's, allOWing time for a more thorough exam ination and explanation of lilldings is ll10re appropri ate than shortening the examination for t he sake of trying to lit in a spccilic hands-on treatment . But such decisions are not always clear-cut and t hey must be made collaborativcly with the patient.
more sensitivity over the lateral el bow than on the other side, but no apparent tightness or sliffness. I said that I thought that modern science could provide a reasonable explanation for her problem and that I should go over that IIrs t I a lso said t h a t there were a few things I could do and that there were many t hings she could do to help. The intercha nge below was my attempt to explain the problem: .
Clinicial1 I think after listening to your story and examining you. that there has to be some un heal thy. unfit tissues in your lower and middle back. Certainly there are many tender joi nts and sensitive nerves, and a lthough I haven' t tested muscles yet-I will la ter-they are sure to have lost some of the norma l heal th and vitality they had before your problem began. You probably did strain some joints and muscles in your back a few years ago, as wel l as probably having some nerve irrita tion . which caused the leg pain. and these tis sues are still a bit sensitive. However. one thing is for sure, over the last year the inj ured tissues h ave had every cha nce to heal and these present pains a ren't real ly serving the original purpose of the pain, which was a warn ing and a call to action. R uby OK, I would l ike to get things a bit health ier. but how? It j ust h urts so much. And why doesn ' t it get better? There has t o b e something wrong i n there. I am n o t p u tting it on . Clinician I know you aren't and we have to answer those important q uestions. I think [ can offer you a
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3 ONGOING LOW BACK, LEG AND THORAX TROUBLES, WITH TENNIS EL BOW AND HEADACHE
good scientillcally based explanation of why your back is still so sensitive. Ruby I'm all ears. Clinician Your once-injured joints, muscles and nerves have had plenty of time to heal. As you know, even a broken bone will heal up nicely in a couple of months. A lso, by your decreased activity you have protected yourself. maybe overprotected , from re-injury. But for various reasons, which we' ll explore. the tissues are still unhealthy and sensi tive. However, they can be made a bit healthier and made to move better, given more blood , and the oil in the jOints can be made healthier and slipperier. They are sensitive but they are crying out for movement. Ruby OK. but why is it still hurting and shouldn't my attempts to move make me feel better? I always used to feel great after exercise. It's not for the want of trying you know. A couple of times 1 have said 'sturr it' and gone and exercised and wal ked lots, but I really pay for it afterwards, sometimes not even sleeping for a couple of nights. Clinician Well , it's partly those sensitive unhea lthy tissues and getting the right balance for the amount of exercise, but it's probably also because there has been a few sensitivity cbanges right throughout your nervous system. Ruby What on earth do you mean by that? Clinician Well , there has been a lot of resea rch into pain mechanisms over the last few years. We now know that when there has been a tissue injury, particularly a painful one such as a joint injury or particularly a nerve compression. and if there has been a bit of stress at the time, that the whole ner vous system not only becomes more sensitive, but it can also stay sensitive. Ruby Are you inferring that this is a ll in my head David? Clinician Well no, but yes in a way, in a very real way in your nervous system. I have no doubt about the reality of your pains. This is not easy to explain so bear with me. There are some problems in the tissues but we now know that repeated impu lses into the nervous system will make it more sensi tive. more ready for action. It's a natu ral thing. It happens in everyone, but for some reason, in some people, these nerves stay sensitive. If this hcippens, it means that inputs from other parts of the body like the elbow or the thorax can also report pain . Sometimes old pains that you thought
had gone cou ld come back. It is rather like there is an amplifier or a magnifier in your body which makes everything seem worse than it is. Perhaps you could have handled your son's rock music in the past. but now because of your sensitivity being a bit turned up, it is more difficult. Ruby Sounds possible. Maybe that music does bug me more these days. And I did have bad elbow pains about 5 years ago. I am not sure about some scientists though. I j ust want you to know that I am not making this up. Clinician r don't think you are making it up and if some colleagues of mine have suggested that. then that is unfortunate and all I can do is apologise. But a ll pains are real and I am j ust being a mouth piece for a lot of recent scientilk work. If you want to read about this, r can give you some short art icles which I have written. Ruby Maybe later, perhaps my hus band would be interested. I want to hear more from you . Clin ician Let m e try and express this on a cliagram (Fig. 3 .2 ) . From my examination, I believe that there are a number of tissues that are sensitive and a bit unhealthy. There are also changes related to sensitivity in the spinal cord. r know that sounds awful but, as r said. it happens to everyone. We are l ucky to have this wonderful nervous system that can keep changing its sensitivity depending on how much we need it. r am sure you have heard stories of people who really want to complete a game of sport and during the game they sustain some nasty injury but they can complete the game. We all have the ability to turn the pain system up and down as we need it, and of course some of the changes are automatic. However, sometimes the pain system stays turned up and there is a sort of a magnifier in your system. For example, when I touched your back gently, it hurt. Now there is nothing wrong with your skin otherwise we would see it, but the touch is going into the central ner vous system where it is turned i nto pain. Don ' t worry, this is very common. We all get it t o various degrees and we often see patients where minor inputs such as a collar rubbing on the neck or a little draft seems to cause pain. Ruby (After some time looking at the drawing.) So you are saying that the pains I am having are not really the pains I have got. Clin ician (1 was a bit stunned by this response.) Well. yes and no; perhaps more yes. r think that
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CLINI CAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
t'l
S;o"'J",,,, .s''f�''''J'
1'1""4 �..., Nt;
or
Co e.Jl �,--
Fig. 3 . 2
Graphic description o f the patient's pain state.
/
/ there are some pains/coming from the j oints, muscles and nerves o(the b ack, but you are right and up to date sCientifically if you are thinking that the pains you are experiencing may not be a true rellection of the state of tissue health and healing in the spine. We have to get your whole system less sensitive as wel l as making those tissues more healthy. Are you OK with all this? R u by Yes I think so, but I wan t to discuss this with my h usband. Clinician OK, sure. You can bring him in next visit, if you want. I am going to give you some articles to read and you can give them to him as well. R u by It's comforting to know that I am not alone here. I am looking forward to starting something. What sort of things will I be doing? Clinician You have started already: Sometimes when you know a bit about what is going on it takes a bit of sensitivity out of your system already. R u by Yes that's right I am sure, but shouldn ' t I b e given some exercises? /'
Clinician Let's call it activity rather than exercise. I had to leave the room for 5 minutes. (When I came back, Ruby looked a little concerned.) R u by I don ' t really understand it. I can follow your story about impul ses making the nervous system sensitive. It sounds sensible, but why me? Why hasn't everyone got chronic pain? Clinician Well. there are more people with chronic pain than we ever thought. Approximately one quarter of all Australians have some pain that doesn't go away. In your case, I don't really know for sure, but we can make some educated guesses. First of all, the type of inj ury is likely to be import ant. From the sound of it, we .c an guess that the initial injury may have involved irritation of a nerve. That test when I asked you to slump and lift your legs suggests that there is a bit of irritation or tightness around some nerves, plus there is some minimal wealmess and funny feel ings in the foot . That's from nerve irritation in the back. I f you remember, the test was more sensitive on the right side. There are parts of the nerve close to the spinal cord and near the disc (desk model shown) that keep buzzing for a time after injury. Also, when there is a bit of adrenaline around, which there always is when there is an inj ury and if you get a bit stressed or upset, it will also make damaged nerves more sensitive. A nerve can be sensitive for q uite a while but they nearly always get better, especially if you keep reasonably active and under stand what is going on. Second ly, the sensitivity within your nervous system can be increased for a number of reasons. You could th ink of them as things that are stressing you, some of which you may not be aware of. Novv I hardly know you, but j ust from our two meetings I can see a few reasons for increased sensitivity. For example, with failed treatments and lack of explanation or direction, it is no wonder that you remain sensitive. If you feel as though you have to prove there is something wrong, it naturally only uplifts your sensitivity and this is often the case where there are problems at work. It's a natural survival thing. Walk through the d ark and you become more sensitive to the surrounds. This must be related to the fear of not knowing. Your brain in a small way is fearing for your survival so it lifts the sensitivity and makes more stress chemicals like adrenaline and cortisol. We haven ' t discussed it but it is only natural that
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3 ON G OI N G L OW BACK, L E G A N D THORAX TROU BLES, WITH T E N N I S ELBOW AND HEADA CHE
you would have some concern for the future. I know you love gardening and perhaps even looking at a garden that needs care is stressful. Work issues are probably stressful. There may be other things in your lile that you can think of which may make you a bit sensitive. They may be worth thinking about. Ruby Maybe. At the time of the accident 1 remem ber being very angry. It was very painful but 1 don't think they believed me you know. There had been a few women off work and 1 thinl< they thought we were having a go at the system. It was the same when 1 had elbow problems 5 years ago. And by the way, have you had a look a t the X-rays 1 brought in? Clinician Oh yes. let's look together. There are some changes but they are rea l ly j ust the kisses of time. We all get them and there is nothing to worry about in the bones. Your bones look heal thy. An X-ray can't tell much about damaged tissues; sometimes the CT scans can but your CT scan was great. These are typica I for someone your age, with or without pain. Ruby Well. it's a worry with a l l that wear and tear, but I follow you . Clinician 1 said during the first visit that I would try and answer [our things: what is wrong, how long i t will take to get better. w h a t you c a n d o and what 1 or anyone else can do. Hopefu lly. 1 have begun to answer the first. How long it will take to get better is hard to answer, b u t I am sure that you will be able to function much better once you u nderstand the nature of the pain, that you can edge into it. explore it. even play with it and know i t won't harm you . It may never go completely and there will probably be a few l1are-ups, but this does not mean your management is failing. Thirdly, what can you do? From my examination, I believe that you have every reason to remain positive and being positive will help. S imply, posi tive people make happy healing hormones. We know your nerves are working; we know there is no serious pathology and you are moving quite well. There are a number of things you can do, but it's really all about movement. Edging into pain with less fear is one way. but 1 think you and 1 could also come up with a paced exercise prog ramme; that is, a series of activities that you know can hurt but which are performed short of pain. It is teaching your brain that activities that normally hurt don't
have to hurt. When we set a n exercise programme. we can make some goals, for example increasing time and activity i n the garden. There may always be some pain and you may need to be more active for a while before it settles. For the moment though. try and minimize activities that cause the shooting pain down the leg. I will also d iscuss other management such as using heat and cold and relaxation. Fourthly, what can 1 do? The big picture aims are to get you a bit fitter, a nd happier to move with greater u nderstand ing of your problem. There are some specinc exercises I will add. but they can wait until next visit. This will include some general slump exercises to improve l1exibility and I think it is worthwhile getting some of the local muscle groups around your low back and the front of you r neck more active. I think t h a t in this k i n d of long standing problem, there is unlikely to be a single magic click or d rug or surgery that can fix it. 1 will also expl ain what 1 am doing to the nurse a t your work a n d 1 w i l l ring you r doctor a n d send a shor t report. Appointment 3 Ruby arrived very early for the appointment. She seemed nervous. '1 don ' t thinl< 1 need to come any more', she said. 'I have been thinking about it all night. For years 1 h ave been going to doctors and spe cia lists and therapists and I am sick of it. I rea lly only ever wanted two things. 1 wanted a good examination and 1 wanted to know that I cou ld go back and do more garden ing and more activity without harming myself. I feel I can do that now. 1 a m j ust going to slowly work into it a bit more each day. Minor aches and pains, I won't worry about but I will stop at around half an hour and then I will try and i ncrease that the next week. maybe do some digging and plant ing. That will nt nicely as the days are getting longer now, but I am going to gradually work into more activity, maybe even have a few hits of tennis with my children. I will ring you if 1 need you and 1 would be very grateful if you could explain this to the industrial nurse and the doctor. I will increase my time at work. Thank you very much.' 1 was very surprised. 1 thought 1 had a lot more to offer her, but 1 felt happy with her responses. 1 h a d intended t o manage her for approximately 6 weeks,
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with one visit per week. I had written down my plan for management and it included the following. • Reassess physical signs i ncluding her neurological
signs. • Reassess her hoperuUy changing beliefs and thoughts
about her back, her pain and activity. • I was going to talk more about movement and the
brain, how the brain is hungry for new inputs, how i t changes with loss of normal inputs and how physical exercise is as much for the brain as it is for the body. I wanted to keep adding some inIormation each visit. • Check the need for slump mobilization and spinal exercises. Perhaps treat with some passive as we l l a s active slump mobilization. I may have mobilized or manipulated j Oint segments eventually, if I felt sure she understood where such a treatment fitted in to the big picture. • Try and c hange the maladaptive movement habits. This could begin with the new habit that she had developed to pick thinks up 0[[ the 1100r. Somehow, movements that have been learned to be pain[u l need to b e presented t o her brain i n a non-pain[ul way. This may mean paCing. brea king down movements a n d using different orders of move ment. For instance, there are various d ifferent ways o[ getting up [rom a chair.
• Introduce and mod ify a gradual paced programme
involving time in the garden. I wanted to establish some base activity levels and then increase these. I would also do this with walking. • Discuss other coping measures, including some strategies [or l1are-ups. Strategies could include use or heat , clistraction and relaxation exercises: maybe get a dog etc. • Invite her husband in during one visit (or more explanation. • Initially I thought I could manage her by myself, liaising with the doctor and industrial nurse. I[ there were no quick benefic ial responses I thought that a formal investigation of psychosocial aspects might be relevant, although there were no out standing contributing [actors fou nd in my initial interview. Perhaps I shou ld h ave rung Ruby back. but she had said that she would ring me and I respected that. Her doctor told me she was managing better. About 6 months later. her daughter came into the clinic with an inj ured knee. referred by her mother. 'How's Mum?' I asked. She replied, ' Yeah, not too bad. She's out in the garden a lot. plays a bit o[ tennis. seems happy at work, still grumbling about her back pain though.'
R EASONING DISCUSSION AND C LINICAL R EASONING C OMM ENTARY
II
This patient's perceptions of her experience (i.e.
caused by a secondary hyperalgesia or allodynia).
her understand ing of her problem and beliefs
Specific physical treatment for a patient w ith
about what she could do) were obviously in
chronic pain is discouraged by some and has
themselve s part of the problem and partly
been suggested may even constitute overservicing
hold ing her back from getting on w ith the
while fur ther contributing to the patient's
activities she enjoyed. Clearly your management
reliance on a passive solution. Could you share
in the form of explanation seems to have
your views on how to determine the extent that
contr ibuted Significantly to her ability to do
any physical impairment, such as of neural
more w ithin her pain. I t is also evident from your
mob ility or muscle control in this particular
'plan for management' that in addition to fur ther
case, might still be contr ibuting to a patient's
explanation, you also intended to incor porate
pain and disability and the process you follow to
treatment aimed at addressing some of her
determine their significance ?
general and s pecific physical impairments (e .g. fitness, neural mobil ity) . With the increased under standing of chronic pain there is sometimes the implication that the physical Signs/impairments identified in an exam ination are not relevant (i.e. false-positive findings
• Cl inician's answer If I thought that physical signs were not relevant in chronic pain, then I would not have spent the time performing such a detailed physical evaluation .
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I n addition, I a m not aware of any 'authority' who would disregard the management of relevant phys ical impairment in acute or chronic pai n . The key is the word ·relevant' . A simple way to answer the ques tion of relevance of speciftc physical impairment is to ask. ' is this a physical sign that needs to be altered to make the patient function better?' In addition, some knowledge of the neurobiology of pain can help. Modern neurobiological science makes it clear that many of the physical signs that well-meaning manual therapists in the past have collected are not jus t indications of processes i n the tissue that are presumed to be tested. They are a represe ntation of tissue factors and nervous system factors. Nervous system factors include the representation and mean ing of that particu lar examination technique at that time and in that space. This does mean that fa lse positive findings must occ ur. With Ru by, my j udg ment would be t h at the slump responses were a combination or tissue factors and an upregu lated central nervous system. Hence u relevance j udg ment requires an understand ing of neurobio logy and pathobiology. This knowledge is often lacking in manual t hera py. Specitlc physical impairment does not have to be treated by specific physical techniques. Our physical techniques are j us t one tool. which in the case 01' this patient I may have employed. Specific physical impair ment may also improve with better understa nding. reduction of fear. touch, better general physical health. and return to activity.
D
At the star t of this case , you note that this patient was one of four from your career that 'stand out as s ignify ing changes in my understanding of clinical prese ntations and my professional direction'. Could you comment what was i t about this patient that made such an impression on you?
• Clinician's answer It was the third day when Ruby said she did not need to come back. It was a powerfu l moment as we j us t looked a t each for a period of time not saying any thing. I think we were experiencing similar feelings: she some form of awakening and a realisation of the meaning of pain, wh ile I was sti l l awestruck by the power of taking the messages of pain science to patients.
• Clinical reasoning commentary On completion of the patient initial examination. whether achieved i n the first appointment or over several. the manual therapist should have identi fied speciflc hypotheses in each of the hypothesis categories (see eh. 1 ) . Collectively, these hypothe ses represent the t herapist's 'diagnosis'. which includes his/her understa nding of the problem. the person. the elrects the problem are having o n the person's life. and appropriate management strategies. Huwever. except for very s traigh tfor ward patient problems where the clinical pattern and course or management arc not in any doubt ( i.e. no problem solving req uired) . the hypotheses reached through the examination must then be tested through the managementlreassessment process. As tbe clinician discusses here, even with a hypothesis of a dominant pathobiological cen tral pain mech a nism, physical impairments ( speCific or general) may still be relevant. In fact. speaking at an u npublished pain sem inar in Australia. Patrick WalJ discussed this very issue and sh a red the story of a patient whose central sensitivity and psychiatric symptoms were main tained by a specific physical impairment or his kid ney. The point here is that it can be very difficult to be cer tain in the more complex patient presenta tions what is necessarily relevant and whether identified physical impairments are the result or. or the trigger to. a concomitant central sensitiza tion. Hence. as discussed in Chapter 1 . the reason ing process must continue through the ongoing man agement. Often it is not until physical impairments have been addressed in the management. and the pat.tern of response to such management is revealed. that the therapist can reach a more secure decision. As manual thernpists. teaching is a central com ponent of Ollr management with most patients. While some o f our teaching is i nstrumcntal or pro cedural in the form of specific exercise instruction. much of our teaching centres around aSSisting patients to renecl 0 1 1 their own perspectives (e.g. beliefs and health attitudes ) ; through this self rel1ection and our explanations, our patients learn: that is they acquire new perspectives or u nder standings of their problems and their manage ment. Similarly. through rel1ection, clinicians can
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also learn and acquire new perspec ti ves ( trans
thinking, bel iefs and knowledge limitations). an
I ) , Cri t i c al
attribute characteristic of experts in all professions
self-rellcction requires metacognition ( h igher order
and the means by which clin icians shift their
th inkin g and awareness of, for example. your own
perspectives.
formativc learning, as d iscusscd in Ch ,
Reference Bu tler. D.S.
( 2 000). The Sensitive Nervous System. Adelaide.
Austral i a : Noigroup Press .
• F u rther reading G i fford. L.S. (ed . ) Issues in Pain CNS Press.
( 1 9 9 8 ) . Topical 1. I'almouth. MA :
G i fford . L.S.(ed.) Issues in Pain
( 2 000) .Topical 2. Falmouth. MA:
CNS Press.
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Wa l l . P.O. and Melzack. H . ( 1 999) Textbook or Pain. 4th edn. Edinburgh: Churchill Livingstone.
C h ro n i c low bac k pai n ove r 1 3 years Dick Erhard and Brian Egloff
�
S U BJ E C T I V E EXA M I N AT I O N
A 3 0-year-old Caucasian male (David) presented to the
magnetic reso nance imaging (MRI) sca n , he was
clinic with a chief complaint of bilateral anterior groin
d iag nosed by an orthopaedic surgeon as having a
pain, in addition to severe low back pain (LBP) and hip
herniated nucleus pulposus at L4-L 5 . He described a
area pain. He indicated on a pain d iagram (Fig. 4. 1 )
series of incidents of LBP in the years between being
that h e was experiencing sharp pain i n the lower por
diagnosed and the present time, associated with only
tion of both buttocks and a deep ache on the anterior
minor or even no precipitating events. Each time chiro
and posterior aspects of both thighs. He did not indi
practic treatment, physical ther apy, prescribed exer
cate on the pain diagram that he was experiencing
cise or pain medication brought him some relief.
groin pain. but during the interview he motioned with
David also described how treatment with methyl
his hands in a manner that indicated he felt pain bilat
prednisolone (oral steroids) brought him almost com
eralJy in the anterior groin region. David related that
plete relief on one occasion . However, after the dose
the symptoms were so severe at tin1es that they caused
pack was completed the bu ttock pain returned. Most
him to limp when walking. However. on the visual ana
recently, David had enrolled in a yoga class. His hope
logue scale ( VAS) he rated his pain in the last 24 hours
was that the stretching would help to relieve his
as 2 1 1 0 , both at its worst and at its best (where 0 is 'no
symptoms, b u t he felt that the stretches had actually
pain' and 1 0 is 'extremely intense' pai n) . He also
aggravated his b u ttock pain and they had no effect o n
pointed out that he felt stiff in the low back and right
the LBP. H e a l so indicated that prolonged sitting, s u c h
posterior superior iliac spine (PSIS) region in the morn
as at h i s desk at work, increased his symptoms a n d
ing, but that this resolved as he went about his morning
t h a t movement somewhat alleviated t h e symptoms.
routine. F urthermore. he related a feel ing of his pelvis being 'rotated forward ' . David's hand gestures when describing this pelvic rotation were consistent with a
Questionnaire fi n d ings A medical intal<e q uestionnaire revealed that David
lateral shift of the lumbar spine. Upon questioning, David explained that his symp
had not experienced any recent unexplained weight
toms began approx imately 1 3 years ago when he sat
loss, nor any bowel irregularities or abdo mina! symp
down after a round of gol f. At that time he no ticed
toms. He indicated he had experienced night pain at
right bu ttock pain, and the symptoms had been
the onset of his symptoms, but when further ques
episodic ever since. He reported that the current
tioned he related that this had not recurred in years.
episode was the worst, although at the time of the
He also indicated on the questi onnaire that he experi
clinical evaluation his symptoms had decreased . Four
enced weakness in his legs during walking and epi
years after the onset of symptoms and following a
sodes of his legs giving way (right more so than left) .
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S1
CLINICAL REASONING IN ACT I ON: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
Fig. 4 . 1
Areas o f pain indicated o n the pain diagram b y the patient.
When questioned further about this weakness, David added that the weakness was related to distance and that during this most recent episode he had found it necessary to rely on crutches for ambulation. At the time of his ori1ce visit, he was not using an assistive device to aid him in walking. He also indicated that there had been episodes of bladder urgency, when he
� J D
had to rush to the bathroom on his crutches and quickly void to prevent urinary incontinence. Upon subsequent inquiry, he revealed he had never lost control over his bladder and had not experienced any burning sensations during urination. David denied having any paraesthesia or nwnbness in his extrem ities or groin region.
REASO NI NG DI SCU S SIO N A ND CLI NICAL REA SO NI NG COMME N TA RY
What were your initial thoughts about the pattern of onset of the symptoms, particularly regarding their episodic nature?
Clinicians' answer
Instability is characterized by exacerbation from minimal perturbation . The fact that the patient had had numerous episodes of LBP over the years caused by insignificant or no precipitating events tended to suggest a diagnosis of instability. The onset
at an early age was a lso consistent with this syn drome's presentation, as was the temporary help he obtained from chiropractic care. The patient's use of a supportive device (crutches) with some relief provided further support for the instability hypothesis. Finally, the patient gestured with his hands what appeared to be a lateral shift compatible with lumbar instabili ty. Conversely, the patient did not indicate he was a 'self-manipulator' , which tended to negate the hypothesis of instability, as did his gender.
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4 C H RO N I C LOW BACK PAI N OVER 1 3 YEARS
D
We re you at all concerned about the episodes of
• Clinical reasoning com mentary
bladder urgenc y ? Did you consider investigating this problem furthe r?
• Clinicians'
The clinical diagnosis of 'instability' hHs Jccn bypo thesized as the cause of (or factor contributing to) the patient's symptoms. based on the recognition of typical cues associated with this dinical pattern, and probably considering the fact that this is a disor der with a relatively high prevalence. A second precautionary hypothesis related to potential mechanical causes o f bladder dysfunction is given less weighting, based on an absence of typically associated cues and probably considering the fact that cauda equina syndrome is a disorder that is rarely clinically encountered. Nevertheless. i t is important to note that neither hypothesis has been accepted or rejected at Ihis early stage. which would have constituted an error in the clinicians' reason ing, with additional testing of these hypotheses to be undertaken through further questioning and stan dard physical examination procedures.
answer
Not really. as it was apparent these episodes were not persistent or worsening. Upon questioning the patient further. it was clear he was not describing a spastic bladder (no feelings of constant fu llness or episodes of voiding abnormal ly small volumes of urine) nor any episodes of urinary incontinence (no dribbling as would be expected with a flaccid bladder). In addition. these episodes were not constant and ongoing. certainly not the frequent urgency one would expect from a spastic bladder. He merely had a couple of instances when he had to rush to relieve a ful l bladder and thus no further investigation was warranted at this stage.
Analysis of the i mpact of pai n David filled out a Mod ified Oswestry Questionna ire (MOQ). a 1 0-category inventory of a patient's perception of the disability they have incurred as a result of their LBP (Fairbanks et ai., 1 9 8 0; Hudson Cook et al.. 1 9 8 9 ) . In each of' the 10 categories, the patient is asked to select the statement that best applies to them from six possible responses that vary sligh tly in their descriptions. For example, the state ments in the pain intensity category range from 'The pain comes and goes and is very mild' to 'The pain i s severe a n d does not vary much ' . In addition to ques tions relating to pain, the categories also include questions pertaining to functional tasks. such as sit ting. standing and walking. Each category is then graded from 0 to 5 depending on which statement the Table 4.1 Stage
patient selects. The category scores are totalled and multiplied by two to produce a score out of 1 00'X.. Thus, the higher the percentage the more disabled the patients perceive themselves to be as a result of their back pain. David 's score was calculated to be 46%, indicating that he viewed himself as being significantly disabled when performing daily tasks. An initial MOQ score of 40-60% is one of the criteria used to assign a patient a stage I classification (Table 4 . 1 ; Delitto et ai., 1 99 5 ) . I f the initial score is extremely high (greater than 60%) and the episode is more than a few weeks old. it raises the suspicion of an affective/cognitive component to the patient's complaint. An elevated score on this ques tionnaire may also indicate a serious non-mechanical disease process that is not amenable to physical therapy intervention (e.g. metastatic bone d isease).
The Modified Oswestry Questio nnaire classification system Score
Characteristics
40-60%
Unable to sit for more than 30 minutes, stand for more than 1 5 m i nutes or walk for more than 400 metres without symptom aggravation
iI
20-40%
Has more tolerance for sitting, standing and walking than stage I but instrumental activities of daily livi ng. such as housecleaning or yard work. cannot be tolerated
III
< 20%
Reserved for individuals whose occupation places a high demand on their lumbar spine. e.g. manual labourer or elite athlete
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CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
R EA SONING DI SC U S SION AN D CLINICAL R EA SONING COMM ENTA RY
D
At the conclusion of the interview, what were
Considering the recalcitrant nature and unusual
your clinical impressions? Specifically, what
pattern of the patient's pain, did you think at all
hypotheses were you entertaining with respect
at this time about the pain mechanisms that may
to the source(s) of (and factors contributing to)
have been involved ?
the p'atient's symptoms? Could you please discuss the supporting and negating evidence for each hypothesis.
• Clinicians'
answer
At this stage, the primary diagnostic hypothesis was that of l umbar instability. Supporting evidence for this hypothesis included : the history of multiple episodes of LBP associated with only minor or even no precipitating events • worsening of symptoms with inactivity and relief with movement over 24 hours • pain reduction fol lowing chiropractic treatment in the past but with diminishing returns. •
The sole negating evidence was the bilateral presen tation of the lower extremity symptoms. The main competing hypothesis was a central disc herniation. This hypothesis seemed IU<ely consider ing the bilateral presentation of the patient's symp toms. The reported worsening of symptoms with f1exed postures (sitting) was consistent with this diag nosis. In addition, the use of crutches to assist with ambulation seemed to indicate the profound muscle wealmess one might associate with a massive central disc herniation. The patient's positive response to methylprednisolone also supported this hypothesis. Initia lly, the report of urinary problems possibly appeared to indicate a central disc herniation, but subsequent questioning determined that the patient did not have frank bladder dysfunction. Evidence that tended to negate this hypothesis included the mechan ism of injury. In a healthy individual, a disc herniation would require a large amount of force, such as com pression through a llexed spine or a lifting injury. In this patient's case, a round of golf seemed to be insuf ficient to produce an injury of this magnitude. Furthermore, the patient did not report any kind of sensory disLurbance, numbness or paraesthesia, which one might expect "\lith a herniated disc compromising neural tissue.
• Clinicians'
answer
At this point, the major pathobiological pain mechan ism considered was nociceptive. In keeping with an initial hypothesis of instability, mechanical noci ceptive pain seemed probable. The inability to exercise the proper neuromuscular control over the available range of motion can result in the deformation or tis sues, causing pain. In addition, this mechanical noci ceptive pain response may lead to chronic adaptive pain and an affective component to the condition as the patient avoids activities that are known to provoke pain. The affective component to the disorder m ay result in fear-avoidance of activities that the patient suspects will exacerbate his pain. Did you consider that psychosocial factors may have been contributing to the patient's current and/or previous episodes?
• Clinicians' answer No. The patient was referred to the clinic by a ther apist near his home. It was this therapist's opinion that the patient's problem was not related to psychosocial issues, but that he had been misdiagnosed. In add ition. the patient travelled a long distance and pro vided h is lodging at his own expense. The patient was also self-employed , working in his family's business. He was not l itigating and no avenue of secondary gain could be identitled. He was well-educated and seemed content with his employment and socio economic status. During the interview, his affect, mood and responses were all appropriate. His pain diagram was appropriate in that the source of pain was most likely anatomical and the diagram did not indicate an increased level of psychological distress. The area on a p ain diagram that a patient marks can be related to their level of psychological distress (Margolis et aI., 1 98 6 ) . In this patient's case, the area marked was
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4 C H RO N I C LOW BACK PA I N OVER 1 3 YEARS
relatively small and specific. Finally, it is not uncommon that patients with psychosocial issues have an ele vated numerical pain rating. This patient's rating was only 2 on a 1 0 point sca le.k
Clinical reasoning commentar y Despite the 1 3-year history of lumbopelvic pain and numerous health practitioners consulted. the clin icians have not erred in their reasoning by automat ically assuming that psychosocial impairments would be significant factors in the maintenance of
tEl
PHYSI C A L EXAMINAT ION
The physical examination began with an assessment of the patient's pelvic landmark symmetry via palpa tion and with the pelviometer (Piva et a I . , 2003), a device for measuring iliac crest level in the standing and sitting positions ( fig. 4.2). This revealed a high right iliac crest and a high right anterior su perior iliac spine ( ASIS) in comparison with the left side. The left PSIS and right PSIS were determined to be even. A standing nexion test was then performed, with the examiner palpating both PSIS while the patient Oexed forward from an upright position. With this test, a posi tive result occurs when one PSIS has a greater overal l excursion than its cou nterpart i n relation t o its start ing position. The side that has the greater excursion is regarded as being hypomobile because the il ium and sacrum have moved as a unit (instead of moving sep arately as per normal). The standing Oexion test was found to be positive on the right, whereas a seated Oex ion test was found to be positive on the left. Active lumbar Oex ion, extension and both direc tions of side bending were non-provocative. There
Fig. 4.2
this patient's symptoms and associated activityl participation restrictions. Although, on the one hand. such impairments were obviously consid ered and tested for during the subj ective examina tion, it is clear that l ittle or no supportive evidence for a psychosocial hypothesis was thought to be present. Biased thinking. on the other hand, could have led to such an assumption bein g accepted (despite the evidence to the contrary) and inappro priate psychological management being imple mented. possibly at the expense of appropriate physical management.
Pelvi ome te r f or measuri n g i l ia c crest level in
the stand in g and sitt in g p ositi ons.
was a slight deviation of the trunk to the left of mid line with forward bending. David was able to heel and toe walk without evidence of weakness in either the dorsiOexors or the plantarOexors in both lower extremities. Muscle strength in the remaining major muscle groups of the lower limbs was tested and found to be 5 / 5 . The knee and ankle j erks were brisk and bilaterally symmetrical. Straight leg raise (SLR) was assessed and found to be less than 70 degrees bilaterally. The end-feel suggested that the limitation was secondary to insufficient hamstring length and there was no provocation of LBP or other symptoms, as might be expected with restricted neural mobility. The FABER test (passive Oexion, abduction and external rotation of the h ip j oint) was performed as a quick screening test for the hips and reproduced anterior groin pain bilaterally. In add ition, the lateral aspect of the knee ( both left and right) failed to approximate the table when the patient was put into the FABER test pOSition. Internal rotation of the h ip j oint in neutra l (0 degrees hip Oexion in prone lying) and also i n 90 degrees hip Oexion (in sitting) was then examined passively. There was significant limitation of internal rotation motion bilaterally i n both of these positions. Provocation and accessory mobility test ing was performed by mobilizing from the sacrum through to T I l in a posterior to anterior direction. The vertebral joints in the thoracolumbar region were found to be generally hypomobile. A t this point a measurement of David's chest expansion was made.
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C LI N I CA L REASO N I N G IN ACT I O N : CASE STU D I E S FRO M EXPERT M A N UAL T H E RAPI STS
A tape measure was circumferentially wrapped around the patien t' s chest at the nipple line and meas urements were taken at maximal exhalation a nd i nhalation. The chest expansion was fou nd to be less than 1 cm. Assessment of the passive range of motion
(PROM) for shoulder nexion revealed significant limi tations bilaterally. No fu rther physical examination was carried out at this stage.
R EASONING DISCUSSI ON AND CL INICAL R EASONING COMMENTARY What was your interpretation of the pelvic joint exam ination findings? How much importance did you place on the observational tests, particularly considering their reliabil ity and validity! What is the mechanism by w h i c h the ASIS was high but the PSIS was even!
• Clinicians' answer The i nterpretation of these findings was that the patient was not actually describing a lateral list, but rather a torsion of the pelvis. Normally a com posite of tests is used to diagnose il iosacral or sacro iliac jOint dysfunction . The tests used in this case were the comparison of variolls pelvic landmarks with the patient standing, and also with both the standing ilexion and seated nexion tests. All of these observa tional pelvic tests h ave been shown to meet an accept able level of rel iabi.l i ty (NIOSH. 1 9 8 8 : Piva et aI., 200 3 ) . The more of these tests that are positive (abnormal lI nding), then the more evidence there is that the patient has a pelvic obliqu ity (sacroiliac jOint dysfu nction or leg length discrepancy). Furthermore. when three out of four tests agree that there is a pelvic component to the patient's problem, the weight of the findings indicates that one can effectively and accurately intervene. A leg length inequality will cause the appearance of a high i liac crest, ASIS and PSIS on the side ipsilateral to the long leg. A concomitant posterior rotation of the inominate (fixation at the iliosacral j oint) on the same side as the long leg will cause the ipsila teral iliac crest and ASIS to appear even higher. while both PSIS may appear to be even.
What weighting did you give the previous diag nosis of a her niated disc? What clinical features at this stage in the examination supported and refuted this explanation!
Clinicians' answer Not much weight was given to the herniated disc diagnosis provided by the orthopaedic surgeon. A central disc her niation would be the only possible log ical explanation for the bilateral symptoms. NotClbly, the behaviour of the symptoms was not consistent with this diagnosis. The patient complained of n ight pain while recumbent, a finding inconsistent with a d isc herniation. Recumbency w i l l usually provide some relief from symptoms, as the spine is unloaded. In addition . the patient's constant 2/10 pain rating suggested that the symptoms were not signitkantly affected by any position or movement. A patient suf fering from a disc herniation will likely report radi ation of symptoms with sagittal plane motion: however. this patient's symptoms were generally constant (although the symptoms were sli ghtly worsened in a flexed or Sitting posture). It is also not consistent with a disc hern iation that no position was reported that afforded a ny significant relief. Usually a patient whose symptoms are caused by a disc herniation can nnd some position of comfort, or some mechanical bias to the behaviour of the symptoms. The fi ndings of negative SLR testing and myotomal examination, in add ition to pain-free and full active range of motion of the lumbar spine, also tended to. refute this hypothesis.
Did the physical examination provide any further information to suppor t or refute your p r imar y diagnostic hypothesis of lumbar i nstability?
Clinicians' answer Some further supporting evidence for the lumbar instabi lity hypothesis was provided by the presence of trunk deviation during forward bending.
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4 CHRONIC LOW BACK PAIN OVER 1 3 YEARS
However, several other findings tended to negate this hypothesis:
o
the lack or general muscle Ilexibility (limitations of SLR and FAB ER test motion) • normal lumbopelvic rhythm with forward bending • the lack of joint movement with posteroanterior mobility tesling of vertebrae.
• Clinicians'
•
II
Measurement of chest expansion is not normally a routine part of a lumbar spine examination. W hat was the specific reason(s) that prompted you to measure chest expansion in this case?
W hy did you curtail the examination at the point you did?
answer
The physical examination was ceased at this time because of an increasingly high degree of suspicion of ankylosing spondylitis. In particular, the markedly restricted chest expansion was of concern as it is a sign commonly found in patients diagnosed as having this disorder. A radiological examination was needed to help to confirm or exclude this provisional diagnosis and also to determine the extent of articular involvement (especially of the hip joints) if changes were found.
• Clinical reasoning commentary
• Clinicians' answer A reasonable degree of SuspICIOn of ankylosil1g spondylitis led to the decision to measure the patient's chest expansion. It is a clinically useful test for anky losing spondylitis because a measurement of less than 2 . 5 cm is 94% specific for (or likely to rule in) ankylosiug spondylitis. If a patient tests positive to a test with a high specificity, it is probable he has the disease (Sackett et aI., 1 9 9 7) . Therefore, chest expan sion greater than 2 . 5 cm would be required for a normal test result (Rigby and Wood, 1 9 9 3 ) . The find ings that raised the suspicion of ankylosing spondyl itis were: reported morning stiffness, alleviated by movement constant 2 1 1 0 pain rating over a 2 4-hour period, relatively uninl1uenced by movement • some movement was helpful, but vigorous move ment (e.g. yoga) worsened the symptoms • bilateral h ip involvement (marked decrease in bilateral hip passive range of motion , positive FABER test for decreased motion and bilateral limi tation of SLR) • reduced vertebral mobility throughout the lumbar spine and thoracolumbar j u nction.
•
•
F u rther investigations David was then referred for radiological investigation. The specilk views requested were anteroposterior and lateral views of the lumbar spine, oblique sacro iliac jOint views, and an erect anteroposterior view of the pelvis including the hip joints. This series was
What led the clinicians to test specifically for anky losing spondylitis. particularly considering t hat this condition is relatively uncommon and the patient had been previously examined by many other health practitioners (including medical special ists)? It would appear that the inability to ' n l ' sa t is ractorily the various clinical Ilndings to t he more obvious mechanical diagnostic hypotheses (e.g. lumbar instability, disc herniation, pelvic jOint impairment) led the clinicians to consider or 'sus pect' other less frequent disorders in an attempt to explain the patient's perplexing presentation bet ter. Although ankylosing spondylitis was not men tioned earlier in the clinical examination process as a potential mechanism/source for the symptoms. it had not been excluded either. That is, the hypothe sis of ankylosing spondylitis probably rose through the ranks of hypotheses as the h igher-ranked pat terns/hypotheses initially generated failed to with stand testing. The clinicians have maintained an open mind and critical outlook during the exami nation. resisting the temptation and avoiding the reasoning error of accepting an hypothesis that may be more prevalent or favoured but which only partially explains all the clinical I1ndings. ordered based on a high index of suspicion of anky losing spondylitis. Below is a synopsis of the findings detailed in the radiographic report. Anteroposterior and lateral views of lumbar spine. Essentially a normal lumbar spine. Mild straighten ing or the anterior margins or the vertebral bodies is of uncertain significance. While this finding may
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C L I N I CAL REASO N I N G IN ACT I O N : CASE STU D I E S FROM EXPERT MANUAL THERA P I STS
Fig. 4.4
Oblique view of the sacroiliac joint showing
mod erate sacroiliitis.
Fig. 4.3
Lateral view of the lu mbar spine demonstrating
mild straightening of the anterior margins of the vertebral bodies. These findi ngs are consistent with ankylosing spondylitis.
represent a normal variant. these c hanges may also be seen with early ankylosing spondylitis (Fig. 4 . 3 ) . Oblique views of sacroiliac joints. Changes are com足 patible with bilateral moderate sacroiliitis (Fig. 4.4). Ante roposterior view of pelvis. Mild to moderate hip joint osteoarthritis and moderate bilateral sacroillitis (sclerosis and joint irregularity) is evident (Fig. 4 . 5 ) . These findings led t o a request for a HLA-B 2 7 assay. The results of this test were positive for the presence of B 2 7 an tigen.
Fig. 4.5
Anteroposterior view of the pelvis showing
moderate hip osteoarthritis (white arrow) and moderate sacroiliitis (black arrow).
R EA S ONING DISCUSS ION Following the physical examination you were obviously suspicious of the presence of ankylosing spondylitis. Did you consider any other possible diagnoses!
Clinicians' answer After the physical examination. it was al most certain the diagnosis was ankylosing spondyl itis. At this
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4 C H RO N I C LOW BACK PA I N OVER 1 3 YEARS
'fa
po int. there really was no other explanation fo r the
The patient's initial repo rt of insidious buttock a nd
patient's symptoms and patterns of movement l i mita
PSIS pain a lso added to my suspicion. as these are
tion of his trunk and l a rger joints. The radiographs
common symptomatic sites for sacroiliac joint pathol
were ordered to add weight to the diagnosis and
ogy. Furthermore, the patient received almost complete
so that: a referral to a rheumatologist could be
relief of symptoms while on ora l steroids (methylpred
made. There was no plausi ble competing hy pothesis
nisolone). The presence of bilateral symptoms. u npro
that cou l d explain the res u l ts of the physical exami
voked by any movement and in the presence of a
nation. Perhaps if you took a few I1 ndings from the
negative neurological examination, also increased the
physical examin ation in isolation . then you may be
suspicion of a systemic cause. Additional support was
able to suggest some other explanations. However. if
provided by the bilateral loss of PROM of some large
all the physical I1ndings are considered together,
peripheral joints (hips and shoulders). the reduced
along with the history and symptom behaviour, then
mobil ity of vertebrae in the thoracolumbar transition
a diagnosis of ankylosing spondylitis is strongly
region and the decreased chest expansion during
supported.
in halation. The
radiological
changes
added
substantial
What clin ical feature i n itially caused you to
support to the working hypothesis of ankylosing
become suspicious of a syste m i c inflammatory
spondylitis. In particu lar. bi lateral sacroiliac joint
disease'
involvement (sacroiliitis) is pathognomonic for anky losi ng spondylitis and i s a radiological prereq uisite l'or its diagnosis. The bil ateral sclerotic cha nges of
• Clini cians' answer
the hip joints in a patient of this young age a lso
The long history of symptoms without a preci pitating
provided weight to the hypothesis. as in one-third
event and the insidious onset of symptoms at j u s t
of cases of ankylosing spondylitis there is involve
17 years of age, a s well a s t h e constant natu re of
ment of the h ip and/or shoulder joints (Koopmcl!1 ,
the symptoms. a l l tended to initially raise suspicions.
1 9 9 7 ).
t h a t t h e bu ttock p a i n w a s n o longer present. H i s physical examination fi nd ings were also un changed David was subsequently referred to a rheumatologist
from his i nitial consu ltatio n . It was decided to treat
near his home. On his follow-up visit 3 weeks after
his
commencing medical ma nagement for ankylosing
tion and a reduction of his pelvic land marks was
spondylitis the MOQ score was
obtained. In other words, the pelvic obliquity was no
1 8 % and his pain
ili osacral
j oint
dysfunction
using
ma nipu la
intenSity was a constant. unvarying 1 / 1 0 on the
longer present a nd his pelvic landmarks were now
VAS. The pain diag ram remained unchanged except
symmetrica l .
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REAS O N I N G D I S C U S S I O N A N D C L I N I C A L R E A S O N I N G C O M M E N TARY
You administered a
MOQ
as part of you r
examination and fol l owing t h e patient's referral to a rheu matologist.What particular i nformation
• Clinicians'
answer
The MOQ was admini stered in part to gather i n for
were you seeking with this test and how did you
mation in lieu of asking q uestions d u ring the subjec
use that i nfo rmation? Do you use it i n stead of
tive examination. and in part to assess the pa tient's
asking certain questions in the su bjective . exam i nation?
progress after being treated by the rheumatologist. A comparison of the initial and fol low-up MOQ
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C L I N ICA L REASO N I N G IN ACT I O N : CASE STU D I ES FROM EXPERT MANUAL T H E RAPISTS
results also gave an insight into which activities were still difficult for the patient to perform and which activities were now easier. This information helped to guide the physical examination at each appointment. Many practitioners would be tempted to categorize a patient with a 1 3 -year histor y of LBP as beyond physical intervention and
level of 9-10110 and yet be in no obvious cardiovas cular d istress, with normal heart and breathing rates evident. In the end, this patient could be di agnosed. Perhaps it took time [or his pattern of limited motion to emerge to the point where it was recognizable. It is likely. how ever. that in the past this patient olTered clues as to his underlying condition that went unnoticed.
requir i ng psychological management. What led you to pursue a physical diagnosis despite the failure of numerous cl inic ians in the past?
• Clinici ans' answer This patient travelled a considerable distance at his own expense and on his own initiative and presented as a straightforward patient seeking help. That is. the patient's physical limHations as found in the physical examination were consistent with his reported level of disability (as determined by the MOQ score) and with his level of distress ( as indicated by his pain diagram and numerical pain score). Notably. his pain diagram. pai n VAS rating and MOQ score were all reasonable. The patient's pain diagram was best described as being consistent with a nociceptive d isorder, i . e. he did not complete the diagram i n a non-anatomical pattern with l arge areas marked with multiple descriptors, as is common [or the patient in psychological d istress. His MOQ score was 46% a n d we lind that most patients in psychological distress will have a score of 70% or higher. Finally. his pain VAS rating matched his demeanou r and apparent level of distress. Usually patients in psychological distress will claim a pain
• Clinical reasoning commentary Two particularly important aspects of the reasoning illustrated throughout this case are the use of screening questions and the combined application of patient questioning and questionnaires to acquire infonnCltion. Screening questions were used to obtain a full picture of the patient's symptoms. behaviour of symptoms. history. possible non musculoskeletal sources and potential psychosocial factors. While patients wiU volunteer what they feel to be important. i t is critical that manual therapists thell screen further in order to gain a complete understanding or the person's pain experience. In this case. questions regarding precautions and con traindications 10 physical examination and physical treatment (i.e. red Ilags suggestive of sinister pathol ogy) were essential. Similarly. screening for yellow. blue and black flags. as discussed in Chapter 1 . are important to identity aspects in the patient's pre sentation that may represent obstacles to recovery, either as a manifestation of a central pain compo nent or highlighting that the patient may be at risk of developing chronic pain.
References Delitto. A.. Erhard. R.E. and Bowling. R. W. ( 1 995). A treatment-based approach to low back syndrome:
pp. 187-204. Manchester. U K : Manchester University Press.
Hicks.
Koopman . W.J. (1997). Arthritis and
identify ing and staging patients for
Allied Conditions: A Textbook of
conservative treatment. PhySical
Rheumatology. 1 3 th edn. Vol.
Therapy. 75. 470-489.
London: Williams &Wilkins.
Fairbanks. J.C.To Cooper. J .. Davies. J. G .
Piva. S . R . , Erhard. R.E . . Cbilds. J.D. and
I.
Margolis. R . B . . Tai l . R.C. and Krause. S.).
G. (2003). Reliability of measur
ing iliac crest height in the standing and sitting position u sing a new measu rement device. Journal of Manipu lative and P h ysiological Therapeutics. in press. Rigby. A.S. and Wood. P.H.N. ( 1993).
et ill. ( 1 980). The Oswestry low back
( 1 986). A rating system for use with
pain disability questionnaire.
patient pain drawings. Pain.
Observations on diagnostic criteria for
Physiotberapy. 66. 2 7 1- 2 7 3 .
24. 5 7-65.
ankylosing spondylitis. Clinical ,Uld
Hudson-Cook. N. . Tomes-Nicholson. K .
N10SH ( 1 988). Low Back Atlas o f
Experimental Rheumatology. 1 1 . 5-12.
a n d Breen. A . (1989). A revised
Standardized Tests and Measurements.
Oswestry disability questionnaire.
Washington. DC: US Department of
Rosenberg. W. and Haynes. B.R.
In Back Pain: New Approaches to
Health and Human Service. Center for
( 1 99 7). Evidence-based Medicine: How
Sackett. D.L.. Richardson. S.w..
Rehabilitation and Education
Disease Control. National Institute lor
" 0 Practice and Teach EBM. Edinburgh:
(M.D. Roland and J.R. Jenner. eds.)
Occupational Safety and Health.
Churchill Liv ingstone.
Copyrighted Material
Unnecessary fear avoidance and physical incapacity in a 55-year-old housewife Louis Gifford
ďż˝
S UBJECT I V E EXAM I N ATI O N
Lara i s a well-preserved 55-year-old woman. She is
Lara has a chronic pain problem relating to her back
married to Raymond, who is an arch itect, and they
and legs, but in particular to her feet. She has pain in
have one son who is a general practitioner. They are
both feet. but also pain and dysaesthesia lO both legs,
we l l off and have a lovely home in a very pleasa n t
and pain in her right groin, buttock and lO the m..id dle of
region of rural England.
her back (Fig. 5.1). She also has intermittent problems
Fig. 5.1
Body chart illustrating the patient's symptoms.
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61
C L I N I C AL REAS ON I N G IN ACTI ON: CASE STUD I E S FROM EXPERT MANUAL T H E RAPI STS
in the low thoracic region and at the base of her neck, and she frequently gets headaches. Lara came 2 00 miles to see me. She was recom mended to me by two physiotherapists who had been working with her. She was p leasant on the phone and
said that she was desperate. I inter viewed, examined and began her management in two sessions spread over 2 days. The first session, which was entirely interview, took 2 hours, while the second lasted about 1.5 hours.
REASONING DIS CUSSION AND CLINICAL REASONING COMMENTARY
II
You decided to spend the full 2 hours of your first appointment entirely on interviewing this lady; this clearly indicates the importance you place on this initial session and on the information you will obtain. Could you briefly outline the broad aims of your initial interview and how you use this information to guide your subsequent physical examination and management.
• Clinician's
answer
There is no doubt that complex long-standing problems take time to understand fully. The broader more bio psychosocial approach that is taken here requires a full appreciation of patients' problems and the way in which their problems have affected them and those around them. Interview, and discussion during interview. is also a very powerful and important part of the management process. It provides the information base that clictat�s the best direction in which to proceed and it reassures the patient that I understand the problems that they are facing, as well as the nature of the presentation, There were several key aspects to the initial interview. • To find out about her situation now compared with
how il' had been before the problem started. In par ticular, to find ou t how much she does physically in comparison to the situation previously. This gives an understanding of her disability level and some idea of shorter and longer-term goals. • To find out what she feels is wrong, what the pain means to her, and what she feels about the future. • I also needed to find out about her expectations of me and what she was expecting from our sessions. Much insight is gained here with discussion of pre vious treatments and investigations, treatment effectiveness, and how messages and information given have been interpreted. • I needed to feel comfortable that no serious condi tion was present that would be more appropriately managed within or alongside some form of medical
intervention. Information here may lead to appro priate physical testing later. • I wanted to get enough information so that together we would be able to plan a way forward. • I needed enough information about her symptoms to be able to understand her problem in terms
of pain mechanisms and all the current physical and any 'emotional/cognitive/psychological' issues relating to the problem. • It is necessary to have a full appreciation of all psycho social factors that may impede management. With respect t o your aim to ensure that no serious con.dition was present, were you concerned/worried at this stage that her bilateral lower limb symptoms could reflect spinal cord involvement?
• Clinician's answer Not really, although it is always a possibility and should always be entertained in every patient. Important 'spe cial questions' and physical/neurological tests should never be left out. however confident one feels. The rea son for my confidence here is threefold. First. patients with chronic pain l ike Lara have usually been seen by many doctors and specialists and have often been thoroughly biomeclically screened already.' Secondly, if there was signillcant spinal cord involvement, clues should be picked up during history taking. Thirdly, bilateral lower limb pain is not uncommon in many chronic pain states and may be a reflection or central proceSSing/central mechanism factors rather than gross or franl< cord pathology.
Clinical reasoning commentary
The clinician's account of the 'broader more bio psychosocial approach' he takes with this sort of complex, long-standing problem is consistent with
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5 UNNECESSARY FEAR AVO I DANCE AND PHYSICAL INCAPACITY IN A 5 5 -YEAR-O L D HOUSEWIFE
what Mattingly
(J 99 1) has described in the clinical
reasoning literature as attending to the patient's 'i1lness expericnce·. As discussed in Chapter 1. a
Main et aI.,
2000; Malt and Olafson. 1995; Strong. 20(0).
1995: Watson.
The clinician's rderence to screen.ing for potcnLial
(Le. precautions and contraindi
patient's illness experience. or what is synonymously
serious conditions
described as 'pain experience' in the pain science Iiter
cations) and attempting to understand the patient's
aturc. refers to the elTects patients' problems have
symptoms in terms of pain mechanisms (Le. patll0-
on thcm. and those around them. psychosocially.
biological mechanisms) reveals a structurc to his
Understanding thc context. also called 'narrative rea
knowledge and thinking consistent with the hypoth
soning' (Fleming and I\IIattingly. 2000: Jones et al.. 2(02). requires attempting to undcrstand the patient
esis categories discussed in Chapter 1. This is not
as a person, including their pcrspective of the prob
thc development of these categories (Gifford. 1997:
surprising given he has personally contributed to
beUds. desires. motivations.
Gifford and Butler. 1997). but it also highlights how
emotions. dc.). the basis of tbeir perspective. and how
a framework. as prOVided by categories of hYPoLhe
the problem is affecting their life. Understanding the
ses. can assist in organizing ooc's knowledgc and
lem (e.g. understanding.
person. in addition to the problem. as identilled by the
guiding examination and reasoning. The clinician's
clinician as a kcy aim of his interview asscssment. is
aim
increasingly being recognized as a signi!1cant variable
together we would be able to plan a way forward' is
influencing patient outcomes (Borkan et
al.. 1991;
Feuerstein and BcaWe, 1995; Lackncr et al.. 1996;
of
gaining sufi1cient information
'so
that
testimonial to the 'collaborative reasoning' approach to his assessmcnt and management.
was markedly worse following it. She regretted ever
Initial assessment interview
having the surgery and her husband added that he
Lara's husband accompanied her for every session. She met me with a smile. but she moved very stiff ly sighed easily. She sat bolt upright. back in extension. knees at right angles and together. and her hands rested on her thighs in a very symmetrical and stylized way. The history of Lara's problem can be summarized as follows.
believed that her problems really stemmed from the operation . He was notably disgruntled about it. She recalled that her low back was agony at the time of the operation. but that it 'more or less' cleared up once she got moving afterwards. 3. After a further
8
months.
Lara's
back
pain
returned. again for no apparent reason. This time the pain had increased its area to include the low
1. About 5 years ago. she had a fairly nasty low back
right buttock. The physiotherapist told her that the
problem. which she was told by her physiotherapist
bulge was likely to have increased and was starting
was a disc condition. There was no history of any
to irritate the sciatic nerve. She said that the thera
injuring incident and in the past she had only suf
pist went through all the postural and movement
fered minor. odd back pains that lasted for a few
'dos and don'ts' and some similar previous exer
days. This episode recovered with repeated exten
cises. As well as giving the exercises. the therapist
sion exercises in one week. I asked Lara if she went
treated her using 'pressures on the back' and ultra
back to 'normal' activities after this and she replied:
sound. She remembers often feeling very stiff get
'The therapist helped me understand about fluid
ting off the couch after treatment and that the
movement inside the disc and that bending pushed
exercises often left a lingering pain further down
the fluid backwards and made the disc bulge
her right leg. After 10 treatments over 6 weeks.
towards my nerves. She also taught me good pos
treatment stopped. She recalled the physiothera
ture to prevent this happening. As a result all the
pist saying that the disc would be healed and that
pain went. but in order to be careful of the fluid
further treatment was unnecessary. I asked Lara if
t stopped most of the gardening and have always
she had felt better. to which she said. 'To be honest.
been very careful with any back bending.'
I felt quite depressed: my movements were better
2. Eight months later. Lara had a hysterectomy and
but my pain was much the same and I had some
colposuspension (remodelling of the vagina) oper
new rather odd feelings in my right thigh and
ation. She had complained of some urinary leakage
calf. which t was also starting to feel in my other
prior to this operation and noted that the back pain
leg. The overall intenSity of the pain was perhaps
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·
.
C L I N I C AL REASON ING IN ACT I O N : CASE STUD I E S FROM EXP E RT MANUAL T H E RAPISTS
slightly less, but 1 was getting worried and it was starting to really trouble me at night.' 4. Lara was advised to see a local chiropractor by a close friend. She was diagnosed as having four major contributory problems. These were described as facial distortion ( 'some sort of jaw distortion'), C2 fixed in a left rotated position, unequal leg and arm lengths and what the chiropractor described as the worst sacroiliac (SI) blocking he had ever seen. 1 asked Lara how she had felt about that? She said. 'I remember feeling pleased to start with, that he had found something, he seemed very confident that it would all be put right very easily. Later on 1 started to dread going. when 1 think about it now 1 felt that he started to make me feel that the lack of progress was my fault. 1 also started to worry that the things he said were wrong, were impossi ble to overcome. By the end I got worse and stopped going.' Treatment involved a series of regular but very quick adjustments to her head and neck and some 'pressing on the roof of her mouth ' . Lara was warned t o stop a l l swimming s o as not to upset her SI jOint: 'He told me to stop the physio therapy exercises and concentrate on my neck posture.' 5. A further 4 months later, Lara's doctor referred her to an orthopaedic consultant after radiographs revealed modest degenerative changes. 'He said that I had normal wear and tear on the X-rays but there was the possibility of spinal stenosis. 1 had a scan that revealed moderate disc bulging at L5-S1 and no signilicant stenosis.' What happened from there? Lara said, 'I remember feeling very empty, very tear [ul and almost embarrassed to start with. He made me feel as if I was making it up, I remember the com ment he made, "you've got the same back as every one else of your age on this earth", and then he said, "the best thing you can do is 100 sit ups a day and go swimming". About a week later, 1 started to feel very angry that! hadn't been believed, but even my hus band seemed to side with his view-when he came in from work his fIrst words were usually, "have you done your sit-ups?".' 6. Through the next few months, Lara's doctor treated her for mild depressive disorder with amitriptyUne (tricyclic antidepressant). She was also given 'pain kiUers' (ibuprofen: non-steroidal anti-inllammatory agent) and co-proxamol (dextropropoxyphene hydrochloride plus paracetamol: compound opiate analgesic).
7 . Within a couple of months, Lara started to suffer
8.
9.
10.
11.
from stiffness in the back o[ the thighs on bending. She also had low back pain. buttock pain and lumbar stiffness. In desperation, she returned to her physiotherapist, who concentrated on the disc bulge. She had eight tTaction treatments, which helped to start with, but pain soon returned. In addition, she was given a corset to wear all the time. Lara could not remember any exercises being given that were not stopped because of exacerba tion of the pain. She returned to the chiropractor. who 'cracked' her neck and adjusted her SI joint. After four treatments and progressively worsening pain, the chiropractor referred her back to her GP, who organized an appointment with the local rheumatologist. Lara saw the rheumatologist 2 months later. By now she was only waUdng around the house, rarely went out of doors and had stopped all social engagements. Her doctor son was keen for her to see a psychiatrist. 'I was starting to think that I had something that no one else in the world had ever experienced, and that because it was so new and nothing could be found to reasonably explain it, the only rational way for doctors to see me was in terms of some kind of madness! Even my son was seeing me as a mental case. The rheumatolo gist said that I was "atypical" and that I did not have any j Oint rheumatism. He actually took me seriously. listened and arranged for some blood tests. Once the results came through negative, he referred me to the local pain clinic. Here, I was given acupuncture and TENS (transcutaneous electrical nerve stimulation). After three treat ments, I had terrible pains in the balls of my feet, which the physiotherapist said was a good thing! But the pains got worse and worse and she then referred me to hydrotherapy. She said that I had tight nerves that need moving and stretching.' The hydrotherapy was the first step towards some improvement; Lara enjoyed the movement in the pool and the pain was masked by the warmth . She said she felt very safe moving in the pool and after 4-5 weeks found that she was able to do some simple back exercises lying down at home. She made further gains using the Alexander tech nique (Barlow. 1981). She continued through early the following year 'managing' reasonably well and even getting to
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5 U N N E C ESSARY FEAR AVO I DANCE A N D PHYSICAL I N C A PACITY I N A 55-YEAR-OLD H O U SEWI FE
about 70% of normal for several months. Lara contlnued with physiotherapy and the Alexaoder technique. Physiotherapy she described as 'lying on my tummy for 20 minutes while she loosened me. then some stretches to my legs and ultrasound on my feet. I had four major exercises. Tightening my stomach for 5 seconds ten times three times a day. then the same but also tightening my buttocks at the same time. holding this tension and arching and flattening my back 1 cm while I was sitting. and then lying on the noor and stretchillg my leg up the door frame. The main message was that my back was unstable and that muscle tone had to be
increased to prevent it slipping out of place. I was also instructed to never bend without tightening my stomach.' 12. Five months later Lara suffered a severe setback in pain and also had treatment for depression again. 13. Lara was referred to a neurosurgeon 2 months later. who offered to do a sympathectomy. Her comment was: 'How can I go ahead with an oper ation when the man I saw didn't even examine me. peered at my notes. scans and X-rays. asked two questions about my cold feet and said that my only chance was to have an operation that cut nerves to improve my leg circulation?'
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
o
What were your thoughts regarding the history of Lara's problems! Include your thoughts on the previous management.
• Clinician's answer If you really follow what happened over time. it is an unfolding story of disastrous management that sequentially reinforced the notion of structural weak ness and abnormality and fear of further damage; this resulted in progressive disability with psychological distress and depressive symptoms. All practitioners have been very structurally based in their thinking and have made no attempt to understand or take on board the patient's thoughts. beliefs. attributions and feelings regarding the nature of the problem. Little has been done to allay Lara's fears and rehabilitate her back to a fuller potential with increased physical confi dence. Therapists appeared satisfied that pam relief was an adequate outcome. Also, common to many similar patients. doctors dismissed the problem as triv ial and inferred mental wealmess on the patient's part. with the unhelpful end result being the conclusion that the patient has a psychiatric disorder. It is worth noting that the therapists/doctors who have lTeated Lara to date have created: • an obsession with upright posture: partially respon
sible for creating unrealistic avoidance and struc tural fear. or behaviour patterns caused by the fear created by therapy • fear avoidance beliefs and behaviour. created dis ability/loss of confidence; this is the result of most
therapists using a 'wealc!vulnerable structure' focus and not helping the patient actively and gradually to restore confidence in spinal movement and back strength alongside their treatments • an unnatural overfocus on the body during move ments; instructions like 'never to bend without tightening the stomach' reinforces structural weak ness perception. movement avoidance, and tension with movement. Normal movement should even tually be trained to be thoughtless movement but pain-focused treatment reinforces a 'back off ' move ment strategy • confusion and conOicting information: doctors and other clinicians have been adopting a blinkered view of the problem specific to their area of interest. Specifically please comment on the key activity/participation restrictions and associated impairments you hypothesized would need to be addressed and the dominant pathobiological pain mechanism pattern you felt was emerging.
In the 'psychological/mental' impairments hypothesis category. it is clear that Lara is upset. unhappy. dis tressed. frustrated, and possibly even angry. There are also many very unhelpful beliefs aod attributions about structure and cause that will need to be add.ressed and overcome before a gradual functional improvement approach can be started (especially those relating to bending). A thorough examination and careful explanation of pain mechanisms would be a useful start in the process. Highlighting structural
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C LINICAL REASONING IN AC TION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
integrity and soundness following examination would be important. It is likely that Lara will have altered movement patterns and significant apprehension pedorming many movements. A great deal of tissue testing is likely to find widespread abnormality. In particular. lumbar Ilexion and lumbar Ilexion activi ties may need careful addressing. It would be unwise to try and be specinc about the pain mechain sm(s) consequent neuroplastic changes in nervous system input, processing and output pathways/networks. the weak and deconditioned tissues. possible minor or moderate degeneration. lack of normal movement patterns and the psychological and social consequences of the whole episode. A single lesion approach to well established cbronic pain states like this one has to be. at best. extremely cautious. A broader biopsychosocial model that incorporates multidimensional and multi level thinking for assessment and management is prob ably the most desirable option (Gifford. 2000a. 2001. 2002a; Main and Spans wick. 2000; Waddell. 1998). Importantly. this does not preclude focussing on spe cinc physical impairments at some time in the manage ment process. Allocating a specific pain mechanism in this type of patient is probably detrimental in that it makes thoughts linger in a focussed way and misses a far big ger picture. A sbift in focus to disability (Le. activity and participation restriction) management is probably the Singularly most important issue. Clearly though, altered. or maladaptive, central processing of sensory and motor information, central generation of pain. maintained peripheral sensitivity, peripheral nerve hypersensitivity and all output mechanisms have a role in presentations of this type. The message is that there is no specific single source targetable by passive therapy interventions. By working on the patient's
thoughts and beliefs. alongside graded return of phys ical function and confidence, we will actually be work ing and manipulating neural pathways responsible for the pain and disability problem (Gifford, 2000b). A key thought is that inputs that improve things like self emcacy. patient sense of control and understanding. levels of distress, physical function and goal achieve ment will have positive neuroplastic effects that will have repercussions for the health of the whole organ ism (see Gifford. 2002b; Lawes. 2002; Roche. 2002).
Lara flfst saw me the following month. The follow ing summarizes the current situation and other perti nent information to her condition.
Symptoms
Family history
Father fine, mother diagnosed as having spinal stenosis in last 2 years (86 years old). Mother always grumbled about her back and never did any Ufting. She also never did any walking or kept fit. Lara has a brother 63 years old. very inactive with a long-standing bad back.
Cli n i cal reasoning commentary
A key aspect of experl reasoning we wish to draw readers' attenlion 10 here is the clear iIIuslration of the c1inician's thinking occurring on multiple levels. Recognizing apparent psychological compo nents. activil-y restriclions anc! physical impair ments within a broader picture of overlapping pain mecbanisms has provided a basis on which man agemenl strategies are already heing formulaled. Despite the emerging pattern. Ihe patient's prob lem has not been pigeon-holed into a scenario where the pain and phYSical impairmenl arc seen to be completely driven by the psychosocial issues. Rather. management of speciJic physical impair ments is hypothesizeo as possibly being required. and the facilitation of 'thoughtless' normal move ment. consistent with motor control retraining philosophies featured in other cases in this book. is Seen as importanl in the ovemll management. Also note here. and throughout the case. the clin iciun uses quot<Jtions from the patient extensively. This reflects how much he listens Lo the patient and the importance he places on the patient's thoughts and feelings ahout their problems.
Lara is constantly aware of symptoms (Fig. 5.1). These rate on the Numerical Rating Scale (NRS) as 8-9 on average; 6 at best and 10+ at worst. The main prob lem is with the feet and back. Symptoms are described as burning. stinging. Ilickers. tightness or compres sion feeling. and cold discomfort. Lara describes being able to hear her feet grating and has the feeling that something inside was stuck and would not move. She describes her feet as having burning pajn yet feeling
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5 UNNECESSARY FEAR AVOIDANCE AND PHYSICAL INCAPACITY IN A 55-YEAR-OLD HOUSEWIFE
cold. The back produces sharp stabbing pains all the
throughout the whole leg. The low back was a con
time when she moves.
stant problem and now the right SI jOint area 'j umps'
Her legs reel tingly and coated in cling 111m from
and often feels weale. The pain frequently moves.
groin to lower one third of thigh. There are odd
She often gets pain in the coccyx region and has a
sensations in her legs: flickering, moving, wriggling,
sharp catching pain in the rig ht buttock. She also
stinging nettles and running water sensations. All
has right grOin pain and when grOin is better, the
sensations are deep, not in the skin. There is no seg
b uttock is worse. Lara does not complaint of loss of
mental pattern: the symptoms are deep and diffuse
sensation.
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
D
Lara's body chart and this list of symptoms
more productive approach would be achieved by investi
presents a rather daunting picture. Could you
gating, understanding and addressing the relevant
highlight your thoughts at this stage? What did
activity restrictions/disabilities/impairments. Some or
you consider were the key features in the body
the 'clues' that lead to these conclusions include the
chart and was there any further support for
chroniCity of the problem, the lack of success with
your earlier hypotheSiS regarding the dominant
interventions so far, the widespread and variable symp
pain mechanism?
tom distribution, and the many deSCriptive terms used. A fina l corrunent here is that it is probably far more pro
Clinician's answer
ductive to think in terms of sources of disability/activity
The body chart (Fig. 5.1) clearly shows that Lara's symp toms are complex, widespread, non-segmental, and not at all typical of common acute and subacute presenta
restriction/impairment rather than sources of symp toms. This sh ifts thinking towards what can product ively be improved rather than what needs to be 'fixed' .
tions. The body chart presentation reinforces the earlier interpretations with regard to multiple mechanisms and sources (relating to input processing and output) and the importance of maladaptive neuroplastic change (central mechanisms). My main thoughts were that the only form of helpful management would be if I could
• Clinical reasoning commentary The clinician raises an important point regarding the use of hypothesis categories. By virtue of being pro vided with a list of hypothesis categories to be con
successfully restructure this lady's understanding of her
sidered when exan1ining and managing patients, it is
problem and the potential of therapy to help/not help;
common for t herapists to proceed and attempt to
then I may be successful in helping her to move on.
D
think through all hypothesis categories from the start with every patient. This is not only cognitively too demanding and hence unrealistic, as pointed out
Given this sort of presentation, how specific were you prepared to be regarding possible
here, it also can be detrimental to understanding
sources of her symptoms at this stage?
some patients' problems. Prematurely focussing on specific structures often occurs at the expense
• Clinician's
of gaining a broader picture of the patient and
answer
The key here I believe is thinking in terms of mul tiple tis sues and at multiple levels throughout, but with the central nervous system as the main player. Being spe cific, \o\Tith our current state of knowledge, is likely to
be detrimental to a multidimensional approach and is unrealistic. The very complexity of the presentation is enough to determine that. rather than try to grapple with hypotheses about specific 'sources' of symptoms, a
his/her problems. There are. of course, no strict guidelines that can be recommended for when spe cific structures should be hypothesized. Patient clues suggesting serious or sinister pathology must be recognized and immediately followed up. How ever, beyond that, the clinician has provided useful suggestions for when specific hypotheses regard ing sources of the symptoms are less useful.
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CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPER.T MANUAL THERAPISTS
Even in nociceptively dominant problems. suc
physiotherapy is indicated. and if so what type of
cessful management wiu usually come more from
manugement is likely to be helpful. The application
treatment
of thorough assessment and balanced reasoning.
directed
to
speciilc
function-related
impairments rather than specific tissues. Therapists
wherein
rarely have their hypotheses regarding sources vali
within the broader picture of pathobiolllgical mech
identified
impairmcnts
arc
considered
dated and allen make the reasoning error of inter
anisms. and in conjunction with known and hypoth
preting patient improvement as substantiating the
esized pathology. will enable therupisls to deliver
source. However. knowledge of common clinical pat
effective management while continUing to improve
terns I()r specilk structures can in many cases assist
their understanding and expund. and evcntually
enormously the recogoition of the problem. whether
validate. their clinical impressions.
• evenings are horrid and ends up lying semisupine
Behaviour of symptoms
on couch
The main ways the symptoms occur are:
• best when half asleep
• standing still causes buroingltightness in the feet. which quickly builds in intensity; it is eased by tal,
• has noticed that symptoms are worse when she is 'uptight'.
ing shoes off; 'releases il11l1e 1 cliately' • sitting also relieves the feet symptoms quickly but it increases the back and thigh pain. making her
Current activity levels
quickly restless
Lara's current activity levels can be summarized as:
• the low back and buttock symptoms increase Vllith sitting and Lara becomes very sore or 'raw' inside;
• swims once a week: manages gentle walking in the
the pain. when severe is tender to touch: max
pool and about one width in total by swimming on
imum sitting tolerance is 20-30 minutes
her back
• never really free of symptoms: they are constant; if they do go it is only for seconds
• waJles 1 mile once a week if she can and walks through the pain. which spreads to toes and set
• back pain is there all the time as a background
tles; the whole leg becomes painful when she stops
aching but when moving gives sharp jabs all the
and it is usually all stirred up for 3-4 days. with a
time
level of pain that forces her to rest off her feet most
• cold feet feeling improves with fast walking but walking makes pain worse afterwards
of the following day • maximum walking time is 40 minutes; prefers fast
• all symptoms aggravated by movement
walking
• shopping in local supermarket consistently aggra
• used to be very busy but describes herself now as
vates the pain in the feet so avoids shopping as much
90% less active than prior to the problem being
as possible (tried changing shoes. adding pads in
severe; for example. she could easily walk
shoes and different corsets-all with modest success
swim 20-30 lengths and carry all her shopping
for a short time. but now nothing helping)
5-6 miles,
bags with no problems
• when pain increases in feet and legs. the coldness gets worse
• spends an average of 4-5 hours doing very little during the day. mainly shifting from sitting to lying
• the colour of the skin of her lower legs and feet change from a blotchy/purple to a deep red when going from sitting to standing
interspersed with small household activities • most of her life is spent inside and at home: she used to be 'out and about' all the time
• night time results in some problems lying on back,
• occasionally does all the housework in a morning
with tail pain. and side lying is best: occasionally
out of frustration but pays for it for several days
wakes aware of pain but always manages to get back to sleep
afterwards • has given all hobbies up; these were gardening (reg
• poor sleeper without meclication
ular). Hower arranging. voluntary work. painting
• copes best in the morning
Oowers and embrOidery (earlier in the year she had
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5 U NNECESSARY FEAR AVOIDANCE AND PHYSICAL INCAPACITY IN A 55-YEAR-OLD HOUS EWIFE
managed some pottering about in the garden but she had not done any flower arranging for 2 years) • has not been on holiday since the problem started because of fear of the problem worsening and wish ing she had stayed at home • has not cooked a meal for other than her husband or been out for a meal for 2 years (previously she had been very sociable, often giving dinner parties and going out with friends).
Any form of concentration has made the problem worse and makes her very frustrated and upset. When asked why she had stopped so much, Lara said that she had a fear of doing more damage, creating more pain, and of something giving or going, with days of resting afterwards. She said she felt weak; activities made her limbs feel heavy and she got very tired very easily.
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
o
There is a certain degree of stimulus-response predictability that is apparent in the behaviour of her symptoms. In your previous answers, you noted that you felt there was strong evidence emerging supporting a dominant processing pain mechanism in her presentation; however, elsewhere (Gifford and Butler, 1997) you have described a common feature of the nociceptive pain mechanism pattern is its stimulus-response predictability. Can you comment on what features of this lady's presentation alter the
keeping with the extent of tissue pathology) are the length of time the problem has been around, the severity and reactivity of the symptoms, and the lack oj' medical evidence for significant enough pathology. One would expect less reactivity perhaps from a severe rheumatoid arthritis presentation. It might be best to reason that Lara has a great deal of maladaptive noci ception going on and maladaptive processing of noci ceptive traffic in the central nervous system as well. Clinically this equates to too much pain and sensitivity for the state of the tissues: hurt does not mean harm.
relevance of the stimulus-response predictability that is apparent in her presentation!
Has any of this new information elicited any new thoughts/hypotheses regarding other pain
• Clinician's answer
mechanisms or sources!
A degree of predictability in symptom response to mechanical stress is common to a great many pain states: it is just as easy to increase and decrease symp toms instantaneously using physical forces and move ments in an acute injury as it is in chronic pain states. 'Processing', along with cognitive, emotional and behavioural responses, are still a feature of all pain, even presentations that are acute and deemed largely nociceptive in nature. However, in the more chronic state, inputs that produce a pain response may be coming from quite normal tissues as well as from tis sues that are in various states of 'iLI-health'-many of which presumably contain maladaptively sensitized and hence over-reactive nociceptors. Further, and central to chronic pain states, is the fact that the pain 'reaction' to physical inputs is often way out of propor tion to what might be 'needed' by the tissues. In Lara's case, features that tend to discourage any thoughts with regard to major nociceptive mechanisms (for which the stimulus-response pattern is more in
Clin ician's answer
Not really. There are some features that might elicit thoughts relating to circulation or even aberrant sympathetic activity: like the cold feet/legs and skin colour changes. Hence, one line of thought could be: maladaptive central processing leads to altered and inappropriate outputs, which, in turn, lead to sensory inputs and more sensations. Another side of the issue is that symptoms lU<e alterations in temperature and blotchy skin may well represent reactions of a very unfit and deconditioned body and are hardly surpris ing. Also, there is the likelihood that Lara's attention system has become conditioned to focus on bodily sensations, thus changes in temperature may be going on normally but, as a result of the maladaptive bias in attention towards her soma, she has become greatly aware of them. These types of interpretation are 'bet ter for the patient' because the message that comes . across is that improved function and fitness, decreased
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body-related worry and attention and more physical
protection Crom related muscle systems and hence
confidence may help to overcome some of these symp
maintain their sensitivity to a high degree. Stronger
toms and sensations. Allocating blame on the sympa
and more efficient muscles, in parallel with increased
thetic nervous system or the circulation, immediately
patient 'physical confidence', may provide a sufficient
'medicalizes' the fmdings and presents the patient
environment for a sensitized tissue or sensory system to
with a problem that has no natural or guaranteed
dampen down its hypersensitivity.
medical solution-presenting them with yet another source of worry and frustration.
Dangers come when clinicians see an altered muscle control finding as key or central to this kind of problem. This is just a small hypothesis with regard to the 'bio'
Some features of her presentation, such as her coping best in the morning, frequent sharp jabs of pain and even her preference for walking fast, could be interpreted as support for a 'postural' or muscle control problem. Do you feel this impairment could be a component of her problem, either as a possible predisposing factor to the original onset and/or as a contributing factor to the maintenance of her symptoms? Could any 'motor control' impairment that may be present be a manifestation of her altered input-output mechanisms, that is a learned phenomenon with implications as to whether and how this should be addressed in her management?
part of the assessment and needs to be attached very strongly to the 'psychosocial' part. I would be very wary of overfocussing on specific 'muscle control' issues in the early stages of patients like Lara. You ask about thoughts regarding a learnt response. The answer is very much so. Pain alters movement pat terns, so does fear of injury and fear of pain and loss of physical confidence. For most patients with chronic pain, these are long-standing features that result in chronically altered movement patterns, which become 'set' as new habits and for many start to feel normal. The secondary consequences to all the musculoskeletal tissues and the circuitry of movement must be vast. Thoughts like this highlight the need for reduction of fear of movement and structural wealmess, and the adoption of adequate but graduated normal functional movement patterns Crom early on. Clearly for Lara, an
Clinician's answer
essential part of her programme should involve normal
This is a good point because it really highlights the
movement patterns and normal recruitment. However.
dangers of focussing on a single 'dominant' pain
I would warn again about being overspecific and too
mechanism. While central-processing issues are so
focussed/complicated early in the management with a
important here, it is foolhardy to deny any input!
patient like Lara.
sensory/nociceptive-related mechanisms. Tissues may be unfit. deconditioned, shortened, degenerate, prone
The following pOints are important alternative hypotheses.
to ischaemic effects, have scar tissues, perhaps even have a modest inflanunatory component, etc. All
• Sharp jabs of pain can be interpreted as 'neuro
these factors may produce a sensory barrage enough
genic'. For example, ectopic impulse-generating
to maintain surricient central activity to affect pain
sites in sensory neurons can spontaneously dis
awareness.
charge and, therefore, have the potential to cause a
An important point is that a 'muscle control prob
sharp jab of pain. EctopiC impulse-generating sites
lem' is not a direct pain mechanism. rather it is an
can also be highly mechanically sensitive; hence
impairment that in some circumstances may influence
small movements produce massive electrical dis
the sensory system. There are a great many of us with huge muscle controllwealmess/imbalance problems
charges and consequently sharp pain. • Coping best in the morning may relate to decondi
who have no pain at all. However, in a weakened or
tioning; in the morning, the body has had some
vulnerable organism (Lara). minor impairments, like
rest and may be best able to cope. Clearly muscle
those relating to muscle control, poor muscle power or endurance properties, may be enough to play a part in
capacity to cope is a very likely part of this. • Walking fast may produce a 'gating' effect. In other
maintaining hypersensitivity. It seems likely to me that
words, the preoccupation with walking fast helps
the sensory nerves and pathways relevant to vulner
to inhibit sensory input relating to pain Crom
able tissues may somehow perceive that they have little
reaching consciousness.
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• Clinical reasoning commentary
education and explanation as an aspect of skilled clini
The signilkunce of one's orga nizution of knowledge to
cal reasoning also stands out in the clinician's caution
the clinical judgments reached is upparent through
regarding apportioning blame to a particular structure
out these answers. The knowledge of pain mecha
or system with a patient where such beliefs are hypoth
nisms and their assodateu clinical fealures. linked
esized to already be contributing to her problems.
no
The importance of re-establishing more normal
doubt. prognosis. clearly underlies the clinician's
movement patterns is recognized but. as with involve
with lhe implications for management and.
views. Patient information is not interpreted in isola
ment of other systems, motor control is considered
tion but considered with respecl to the broader
within the broader framework of altered central pro
unfolding piclure that is emerging: earlier hypothe
cessing. Alternat'ive interpretations for conventional
ses arc supported. in t bis way. the stimulus-response
clinical features of motor impairment are put forward .
predictability common in nociceptive dominant pain
Clearly it is not possible to discern the precise inter
states can be seen also to fil within the pattern of cen
relationship between the patient's a ltered movement
tTal sensitization described by the clinician. Specific
patterns/muscle control and the underlying pain
nocicept ive physical impairments are not discounted ;
mechanisms within a clinical exami nation. However,
rather the likelihood of multiple pain mechanisms
so long as the alternatives are considered. as they are
is highlighted with numagement implications that
here, the manual therapist can then proceed with
include taking care to avoid overattention to any
in terventions directed at altering motor con trol and
single physical impairment. Further. the importance of.
be guided by reassessment of the relevant outcomes.
General health and wellbeing
• the Alexander technique audiotape has been help ful so keeps using this
Her general health and wellbeing are not good:
• has tried visualizing pain away: not successfu l .
• freq uent colds and 'flu. which talce much longer to
Patient understanding of problem and
shrug off than prior to problem worsening
attributions regarding problem
• urinary problems still disturb her • generally low and feels 'blue' most of the time; copes best in the mornings and is tearful on average once a week • worries about her problem and feels very vulner able physically • feels her concentration and memory are not up to what they had been: 'When you do nothing you get out of practice! ' .
Lara felt that her problem rela ted to some wealmess and instability in her back and that nerves were trapped in some way. She felt that her SI joints were still stuck and that she had pelvic torsion and leg length problems. She also thought that there was arthritis in her back. that it might be developing in her feet. and that her neck was ' weak' and vulnerable to being ' locked out'. She had no fear of sinister disease and fe lt that her mother was to blame for passing on her 'weaknesses'.
Current pain management: treatment
Coping
and medication She uses a number of pain man agement methods: • uses TENS for relief of back pain . which 'h elps a
Generally Lara copes reasonably wel l , especially in the morning, but really struggles by the end of the d ay. Her husband and family are very supportive; how ever. her husband displays overly solicitous behaviour
litt le' • hot showers and hot water bottle are ' comfor ting'
toward her, not allowing her to do much. She said that
• takes amitryptil ine ' for sleeping'; this is ' effective'
she had become far less spontaneous since the prob
• takes co-proxamol and diclofenac (non-steroidal
lem began: 'Normal me is in a cage; I have been so
anti-inflammatory agent): little help but takes the
restricted physically for so long that the natural
edge off symptoms
spontaneity part of me seems to h ave disappeared ' .
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CLINICAL REAS ONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL TH ERAPISTS
Her hus band added that 'she is not the same person at
Her thoughts about the future are sometimes posi
aU; it's very sad reaUy ' .
tive; she feels it is curable and she j ust has to fmd the
Patient's thoughts about the future and
negative phases-'I want to die'-and been through
expectations about clinician's input
some ' bad times emotionally ' .
right therapist and therapy. Lara has been through
Lara has come with high expectations for a cure as she has been told that I teach and write articles about 'curing' chronic pain.
R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R EA S O N I N G C O M M E N TA RY How has the i nfo rmation from the interview either suppo rted or not supported yo u r previous hypotheses regarding this patient's p roblems and the dom inant pain mechanisms!
mjuring incident. Understanding or dwelling on the original mechanism o f injury may not be that helpful at this stage. It has happened; i t will have had physical origins and it has now become complex and chronic. There does not appear to be anything serious
• Clinician's answer
biomedicaJly at this stage.
The information from these sections confirms that
but vigil ance should
always be maintained. It seems that there is a family
Lara has a number of factors contributing to her activ
history of back pain-her mother and her brother
ity and participation restrictions. She is physically dis
which should make one think in terms of 'genetic'
abled and deconditioned; the pain mechanisms are
predisposition and social learning/social modelling
multiple. complex and well established, and her psy
factors. Factors like these help us to come to terms with
chological distress strongly features. It also confirms
prognosis and help us to understand j u st a few possible
my feelings about her very passive attitude to recovery,
features that contribute to the development and main
her reliance on medical intervention, and her 'struc
tenance of a problem. It is very unhelpful to attribute
tural wealmess' beliefs about the nature and cause of
blame on factors like these, for we can have little effect
her pain. These findings provide much baseline i n for
on familial features or the effects of the past.
mation. I am starting to understand where she is now
As far as contributing factors in relation to main
in terms of her physical and psychological health and
tenance of activity/participation restrictions and symp
where she would like to return. which is important
toms, a significant percentage of Lara's restrictions
with regard to short- and long-term goals, as well as
(Le, disability) may be put down to the way she has
providing u seful starting points for discussion and
been managed and the resulting beliefs and attribu
action.
tions she has about her problem: for instance, the images she has been given, the contlicting messages,
Given all the information obtained to this point, what were your thoughts rega rding potential contributing factors (e.g. environmental, psychosocial, physical, biomechanical, etc.) to the devel opment and maintenance of Lara's symptoms and activity or participation restrictions (i.e. disabil ities)!
the lack of i n formation or interventions promoting health and function. and the lack of any convincing (to her) examination of structure, Other issues include ongoing high levels of pain that are poorly controlled. the widespread distribution of pain. ongoing and high levels of psychological distress. and a predomin antly passive/avoidance coping style with low activ ity levels. These are all present and are known to be strong predictors of high disability and poor outcome
• Clinici an's answer
(Watson, 2000) . Her husband's understanding, beliefs
The onset of the Original back episode. as in a great
and behaviours are also likely to be contributing to
many patients, could not be related to any specific
the maintenance of her disability /activity restrictions
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5 U N N EC ESSARY FEAR AVO I DANCE A N D PHYSICAL I N CAPAC ITY IN A 55-YEAR-OLD H O U SEWI F E
and participation restrictions and will need t o be
their own rather than bias our investigation to more
addressed (Newton-John. 2 0 0 0 ) .
detailed fmdings. More specific examinations or phys
Many of the above factors are l i kely to have played
ical impairments can sometimes be useful and relevant
a major role in the maintenance of her symptoms too.
later in the management process. Every abnormal
Poor management leading to ongoing anxiety in rel a
reaction. minor movement abnormality or loss o f
ti on to the problem may create a habitual focussing
range is somet hing that can be added t o a list of find
on pain. serving 10 enhance its accessi bility to con
ings that could be worked on and improved. but may
sciou sness and further strengthen its neural repre
not need to be. Most frequently, the restoration o f con
senta tion. Deconditioning. degenerative changes o r
fident movement patterns greatly improves or even
what might be termed ' physical vulnerability' must
resolves many of the physical impairme nts that may be
also play a pa rt as welJ .
noted. The primary aim is to get a disabled human
D
delve unnecessarily further i nto fmding overspecific
Given the presentation that is unfolding thus far. what are your aims for your physical examination?
being active. functional and conlldent again. and not to abnorma lities that may be i rrelevant or o f little value to treatment goals-especially early on i n the manage
• Clinician's answer
ment process.
P hysical examination has signillcance for the manage ment process. fo r diagnosis and for the patient. For the pa tient. we need to seek to reassure via a thorough examination. The patient must feel that a thorough exami nation has been done and that any findings have been given a reasonable explanation. It is wise always to attempt to give reassw'ing messages. rather than cre ate fear. Examination is perhaps one of the most import ant parts or t he management process: an important issue fo r patients l ike Lara is finding features that are good and highl i ghting them as they emerge. rather than searching out the bad and adrung to the worry and confusion. For manage ment we need to explore the extent o f physi ca l impa irment and make sense of i t in relation to the type of intervention offered. Diagnostic examination may have limjted value i n this type of patient w i t h c hronic pain. Clearly the clin ician should always be aware of any 'red flag' features of importance. Howe ver. Lara has had plenty of medical screening tests and is. therefore. unlikely to have any serious disease process. Examining patients like Lara. who have chronic pain and marked activity restriction. does not normally warrant any in-depth or focussed appraisal of mi nor impairments if a broad educational/self-management/ functiona l recovery approach is to be adopted. Here. the early focus of examination is more on observations of function and activity restriction and perhaps some of the more bl atant and relevant physica l impairments. as we ll as patterns of illness behavio ur. tension and fear in movement. and an appreciation of the extent o f the problem and the degree o f the deconditioned state. We basically need to know what the patient can do on
Clinical reasoning commentary As discussed above. it is casy to overattend to the sou rce of the symptoms i n a classic medical diagnos tic sense. While hypothesizing regarding symptom source is lIseful in many patient pre sentations. and here the clinician is i ncreasi ngly more certai n or a ""idely distr ibuted source to much of her symptoms. identifying the contributing factors relevant to the presenting disability often will be as i mportant. or even more important. to a successful o utcome. [n this case. psychosocial factors/impakments are con sidered the key contributing factors. although phys ical impairments. such a s the altered motor control discussed above. may also be seen as contributing factors to the maintena nce of her problems. While experience will enable therapists to recognize pat terns where physical i mpairment is secondary to the broader psychosocial and health/fitness concerns. as is t he case with this patient. prematurely di s counting or not e ven a ssessing for physical impair ment is a s much an error as only looking for specific phys ical impa irments \·vithout regard for the broader psyc hosocia l and health status of the patient. That i s. physical impairment can also trig ger or drive psycho socia l problems. a nd differenti ation of
the relevance of each is best ma de
through thoro ugh assessment. intervention and rea ssessment
of
both
physical/functional
and
psychosocial outcomes. An important aspect of ski lled clinical reasoning. 'which is nicely highlighted here. is t he c1inician's
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incorporation of management within the actual
Management is not reserved until some set point
examiuation. By 'finding features that are good and
when all information has been obtained; instead
highlighting them as they emerge' , the dynamic
it commences with the initi al introductions. espe
nature of
cially
the clinician's reasoning is evident.
through
the rapport
that
is
established
Clinica l reasoning does not occur as a series of set
and th e i nterest that is shown. and conti nues with
steps. Rather. it is a Iluid. evolving process where
the ongoing expl a nations and educat i on t ha t are
hypotheses
provided.
tE
are
continually
being
reappraised.
P H YSI CA L E XAMI N AT IO N
Movement analysis and testing i s not a silent or
get down onto the 110or. She cou ld not walk on tip-toes
totally therapist dominant affair. AU th e time I am
and was very unsteady walking backwards.
asking the patient what they think about the quali ty,
Lara' s husband helped her a lot in undreSSing.
range or particular strength of a movement or test. In
Lara avoided all bending, groaned a great deal and
these types of presentati on. as well as observing the
held her back when it hurt.
poor quality of many movements. I also make a point
Her standi ng posture looked fine: leg length looked
of looking for good quality or relaxed movements and
equal with no obvious major disl-ortion or shill There
may posi tively reinforce what I observe, thus begin
was no evidence of marked muscle wasting in any one
ning a forward moving therapeutic process. Most
individual group. Her balance on either leg was poor.
examinations that these patients have had pOint out the abnormal findings, thus adding to their already negative state. It is useful to hear what the pati ent thinks in rel ation to your thoughts, and it is i mportant to i nvolve them in th e process of analysis-some thing that has usu ally been denied them (Sh orland.
Physi cal goal s Several physical goals could b e l isted a t this stage: • relaxed sit ting and moving. especi ally getting out of a chair, gait and negoti ating stairs • relaxed and faster/more normal walking pace
1 9 9 8).
• i mprove confidence and find a 'physical pathway' or a series of graded exercises or activities to facilitate
Initial observations and functional
tip-toe walking, backward walking, kneeling on all
observations
fours and getting onto the n oor
Lara sat very upright, knees together and very symmet ricaUy poised. She l ooked tense and sh e moved very stiffly and winced going to sit and stand. She kept very still at first and talked very clearly in a slow and monot onous voice. Before asking her to u ndress, I asked Lar a to waU<
• independent dressing/undressing, independence from husband (he needs to be incl uded in under standing pain and suggested process of rehabUi tation) • reducing groaning and gri macing; the aim is to enjoy movement
several times the l ength of the cl inic corridor and
• im prove balance.
to go up and down some steps. She wall<ed with a
We also need to discuss and reassure Lara concerning
relatively sl ow, but normal gait. Walking was recorded as 43 seconds to do four l engths of the corridor (the corridor is about 9 metres l ong and four lengths at a reasonably normal walking pace takes abou t 20 sec onds) . She managed the steps with great effort; she regularly w inced and held herself.
leg length and all the other ' structural faults' she has been told abou t.
Standing examination I informed Lara: 'I want to look at some of the move
She could get into the upright kneeling position
ments of your back and legs. I don' t want you to do
"vi th difficulty but was unwilling to go onto all fours or
anything you don't feel like dOing, I just w ant to get an
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5 Ll N N ECESSARY FEAR AVOIDANCE AND P H YS I C AL I N CAPACITY I N A 55-YEA R-OLD H OUSEWIFE
idea of how good your movements are. We can discuss what you feel or anything you want to say as we go along, is that OK?' 1 usually stand where the patient can see me and first perform the movements to show them what I want them to do. Flexion
Flexion was about 10 degrees. When asked, 'What stops you going further?', Lara answered 'The pain and r know it will stir it up for hours'. We continued, doing and asking. Exte nsion
Extension was virtually nil: '1 hate it' .
perform. with the description 'heavy' featuring strongly again. Lara was surprised at the findings and made the comment in a rather clisconsolate voice: 'I'm more knackered than I thought I was'. 1 then commented back (it was a very opportune time to do so): l\ll this is not surprising. as you haven't been at aU active for a long time. I'm seeing someone in front of me who, like many others similar to you. is in quite a deconditioned state. You're weak and your body has become more sensitive. in part because it is so weak. [ ' 1 1 tell you more about this later. but for the time being understand that the human body has a very good capacity to get strong and healthy if its done in a careful. constructive way and in a way that you don't feel frightened. ' Tests fo r behavioural signs
Side flexion
Side Ilexion was half range and rotation was all trunk on legs with very little spinal movement. Arm and neck movements
With Lara facing me, I asked her to copy my movements as far as she wanted to move. 1 did arms above head, hand behind back, and horizontal shoulder neAlon, all standard neck movements. deep breath in and fully out (noted good spontaneous thoracic and lumbar exten sion and flexion here). Her arm and neck movements were full range, spontaneous and of good , smooth qual ity. When I asked Lara how her arm and neck move ments felt to her. she surprisingly replied, 'extremely difficult and they feel like lead' . She then made a spontaneous comment: 'I've been examined at least 10 times in the last few years and no one has ever asked me what 1 think or feel with the tests. It's almost as if 1 have to relinquish ownership of this body thing that 1 live in, because nobody asks, nobody under stands, because nobody has time to listen, nobody has heard anything. 1 think that the medical profeSSion and all the therapists are afraid of my problem .' Lumbar movement
Lumbar side gliding or side shifting revealed surpris ingly good quality of movement. H i p movem ent
Standing with one hand on the wall for balance, we cUd hip flexion. abducLion and extension. These move ments w'ere generally half range and difficult for her to
Before moving, on I did an additional two tests: axial loading and simulated rotation. Both these tests are used to indicate what Waddell terms 'behavioural signs'. These signs and the reasoning behind them are described in detail in his book The Back Pain Revolution (Waddell . 1 9 9 8). This book is strongly recommended to all manual therapists. Axial load ing involves slight pressure applied to the top of the patient's head with your hands. Simulated rotation aims to rotate the patient's body without prodUCing rotation in the lower spine. In order to do this, the examiner gently rotates the patient from the pelvis making sure the trunk does not twist. Trunk twist can be prevented by getting the patient to stand relaxed with their hands at their sides, holding the patient's wrists or hands against his or her pelvis, and passively directing rotation of the body. Both the tests were posi tive in that they provoked pain in the back. The other 'Waddell signs' are: • widespread tenderness spreading far beyond single
anatomical regions and often over many segments • distracted straight leg raise (SLR) • regional weakness indicated by weakness over many segments and a jerky or 'giving way' response: for example, weak and j erky quadriceps testing, yet the patient can walk • regional sensory change: losses of sensation where the boundaries are beyond the normal innervation field and dermatome distribution. The symptoms may include: • pain at the tip of the tailbone • whole leg pain
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• whole leg numbness • whole leg giving way • complete absence of any spells with very little pain
in the past year • intolerance of. or reactions to. many treatments • emergency
admission to hospital with simple
backache. Add itional phys ical goals
Lara needs a progressive prognm1me to restore conn dence and the function of lumbar and hip movements and muscles. At some stage, a programme lor the upper limbs and neck should be included. Sitting examination
I now asked Lara to sit on a low stool. I sat i n front of her. again doing the movements with her. Movements performed were head into flexion and back up, and slumping the spine. As I did the latter movement I said, 'Can you let yourself go into what I call lazy sitting, like this?' She commented back, 'I haven't done that lor 2 years-I've been told to keep upright to stop the disc bulging'. Remember that her bending was 10 degrees in standing and that her husband had helped her undress-1 had not seen her bend beyond this. I then hugged one knee to my chest and gently dropped my chin part way to my knee: 'What about this movement, or a part of it?' Lara tried and demonstrated quite smooth movement with spontaneous lumbar flexion using either leg. Importantly, I did not say something like: 'See your back is bending ' . All I said was, 'That looks good, now lets try this'. I put my leg back down, placed my hands on my knees and slowly lowered my body forwards towards my knees, saying, 'See what you can do. You have your arms to stop the movement if you are not sure and you can come back up any time you m(e. If you don ' t want to do it. that's nne.' She flexed very slowly but quite well in the spine and hips, probably about half normal range. I then looked at Lara's feet, palpated them generally and did foot movements and muscle tests while she sat with her legs dependent on the treatment couch. Her feet were cold and 'blotchy'. They were hypersensitive to palpation, particularly over the balls of her feet, but active movements were good. AU muscle tests produced giving way (a notable 'Waddell sign'). Her feet looked anatomically normal. with no evidence of swelling or degenerative changes except some slight lipping of the medial joint line of the metatarsophalangeal joint of
the big toe. Lara mentioned being aware or some crack ing and clicking in the ankle joint. My response was. 'Is that concerning you?' She replied. · It makes me feel that arthritis is setting in'. I responded. ·OK. that is an issue that I will put on my list of things to go inLo'. The pOint is that until a patient understands the nature of chronic pain and tissue health issues it is difficult and often unhelpful to discuss individual concerns like this. The best strategy is to listen and acknowledge all the patient's worries and concerns so that they can all be dealt with later on. Calf and quadriceps rel1exes done in this sitting pOSition were quite normal. There was no clonus and the Babinski test was normal. Proprioceptive testing in all lour limbs was normal. There was no major sensory loss to light touch. although diffuse areas of slight nu mbness around the (oot and lower leg were revealed. The key words she Llsed were. 'I know its not as it should be'.
Lying examination
The examination continued in a similar vein in supine lying. crook lying and side lying. Most tests were actively perJormed by the patient and directed or demonstrated by myself. For example. Lara performed the following active movements in lying. • Hip flexion: patient grabs her knee and pulls it
towards her. Lara was very tentative but could do it. • Active SLR: good range to 90 degrees with the oppos
• • •
•
ite leg in 'crook' position. With both legs straight she could not initiate the movement. Passive testing/ assistance revealed marked pulling in the whole leg at 70 degrees ( both legs). If active dorsiflexion was then added, the pulling spread into the foot quite markedly. Active lumbar rotation in crook lying "vaS half range and tense. Active hip abduction in crook lying position demon strated good range. Active pelvic rocking surprisingly showed a good range of llexion, well coordinated and with no wincing! Extension was of modest range and rea sonably relaxed until pain came in. Leg length looked quite normal with reet together in supine and crook lying (she agreed) .
I also p u t a long ruler across her anterior superor iliac spines to assess for any pelvic torsion. Again we both
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5 UNNEC ESSARY FEAR AVO I DANCE AND PHYSIC A L INC APACITY IN A 5 5-YEAR- O L D HOUSEWIFE
agreed that there was l ittle d i iTerence. I even tried to
by your nervous system in terms of pain and d a nger.
get Lara to tilt the pelvis by contracting her b u ttock
I w i l l talk about it more l a ter and I have some hand
muscles on one side and then relax: always the ruler
outs so you can go over it when you are at home . '
came back to level. This raised a lot of questions for her
A l l areas of p a i n were palpated t o establish the
as you can imagine. Rather than d ismiss the notion
extent of the sensitivity state (rather than solely using
of pe l v i c torsion (which might be quite detrimenta l ) .
it to assess for local tissue pathology or local tissue
[ commen ted : 'I w i l l t a l k about a ll this later and I hope
abnormalities). For instance, in side lying it was estab
you will be able to see how it fits in to
bigger picture
lished that very gentle palpatory tests over the back
about the modern understanding of ongoing pain. A l l
and right b uttock a reas were excessively senSitive.
(l.
the findings here. and the findings o f those you have
indicating marked hyperalgesia/allodynia. The reader
seen in the past, need expla ining as far as possible. For
should also be aware that widespread tenderness
now, try and think of your system as having entered
palpation in atypical non-segmental patterns is one of
into a " hypersensitivity state" with all your nerves
the 'Waddell signs' ( l isted above). Again, a n i nd ication
conveying information that too easi ly gets processed
of a maladaptive central hy persensitivity mechanism.
� J -
D
011
R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R EAS O N I N G CO M M E N TA RY
There is some concern amongst some c l i n i cians
hypersensitiv i ty syndrome': thus, offering evidence of
that the 'Waddel l symptoms and signs' can
a marked presence of a m a l ada ptive central ized pain
lead to some patients' p roblems unfairly and
mechanism in the patient's problem a nd the l i keli
non-usefu l ly being categorized as 'non-organic'.
hood of high levels of distress. I rather feel that the
Can you comment on how you inte r p reted this
thinki n g clinician. w ith a l l the s u bjective i n formation
lady's positive signs and the i m p l i cations it held
and the i n formation gathered from the observations.
for the management plan you were formu lating!
should be able to see the state of affa irs quite clearly without recourse to the 'Waddell symptoms and signs ' . However, they are well researched and, like routinely
• Clinician's answer
checking reflexes. they are often well worth quickly
It should be remembered that Gordon Waddeil is an
doing. If severa l of the signs and symptoms are present,
orthopaeclic surgeon whose primary concern when he
they are strong inclicators that a multidimensional
developed these tests was to prevent any unnecessary
approach is v i tal. The fact that two of the behavioural
surgery or the performance of surgery on patients who
signs are present i n Lara adds supportive evidence to
were likely to have a poor outcome. He developed the
the emerging picture that fu rther suggests a complex
'non-organic versus organic' symptoms and signs to
hypersensitivity syndrome, rather than a b iomedically
help to clistinguish between patients with back pain who
alarming presen tation.
had a specific and uncomplicated problem that was amenable to surgery and those whose pain states were
At this stage what were yo u r thoughts regard i ng
far more complex and where surgery was inappropriate.
the information obta i n ed from the phYSical
Unfortunately for many patients assessed by others, the
exami nati o n !
very unhelpful term 'non-organic' suggested that the patient's problem had psychogenic origins and was. therefore, to be discounted as real. What Gordon
• Clinician's answer
WaddeU intended from the list of signs and symptoms is
Because of the chronicity and the subjective presenta
a great deal dUTerent from the way it has been interpreted
tion fmdings, my thinking during the physical examin
and used . His choice of terms was very u nfortunate. Interpreted in
ation of Lara was not overdominated by thoughts
non-judgmental way, these signs
rela ting to speciflc hypotheses about pathology, sources
are very usefu l . My preference is to use them to
and mechanisms. However. key 'red flag' testi n g for
help in classifying the patient in terms of ' chronic
neurological impairment has still been done and should
a
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C LI N ICAL REASON I NG IN ACTI ON: CASE STU DIES FROM EXPERT M ANUAL THERAP ISTS
never be omitted, in my opinion. My main intention was to look at function/activity restriction (and monitor the
in pathological terms. such as ' adverse neural tension' or a Significant peripheral neurogenic mechanism. The
regions or 'sources' of the restrictions) and hence lind
symptom picture is just too long standing and too
out what she could and could not do, thus giving me
widespread to consider in an isolated way. Far better
some idea of where a process of physical recovery might
for now to label this finding as a SLR impairment that
begin or proceed. I guess that in a subconscious way
could be usefully addressed a t some stage in the
observations of movement and willingness to move in
rehabilitation programme.
different positions reveal features that con finn a feeling of structural confidence and that no major biomechan ical or pathological issues are present. For example, I was able to observe good lumbar intervertebral move ment from some starting positions in my silting exam
Favourable ex amination movements! findings
Most practitioners focus on the negative findings:
ination. What this left me with was that her back was
the things that are wrong. While this is u nderstand
capable of physically bending given a situation whereby
able and necessary in treatment models that chase the
fear, anxiety or the notion that the back was bending/
'sources' of a disorder, or that seek-out the impair
vulnerable was eliminated or was being 'gated out' in a
ments to be rehabilitated, it is often worthwhile to start
subconscious way. The key is that this type of situation is
with summing up the positive aspects of the examina
common, and, if anything quite normal. even in acute
tion for this type of chronic problem. Most of the time
back injuries where patients have an understandable fear of bending. It must not be looked upon as the prob
these patients are presented with a rather grim sce nario following standard physical examinations, so
lem being 'non-organic'. Rather. it reveals the extent of
presenting some positive findings is a novel and very
fear of movemen t, but it also reveals a 'way in' to be able
useful thing for many patients. The importance of
to restore back bending confidence for the patient. By the end of the sitting examination, some of the important issues raised were:
using positive reinforcement has been emphasized by Shorland ( 1 9 98) . For Lara the positive findings were: • walking and ascending/descending stairs
• examination revealed a simple way of addressing
• side shifting in standing • bringing knee up towards chin in sitting
lumbar flexion fear/movement loss • matters relating to education about her problems,
• coming forward in Sitting
e.g. arthritis a nd cracking/clicking • education about the process o f physical recovery.
• feet movements in Sitting • all knee movements in sitting
for example, that bending of the spine is safe. nor
• hip flexion and active SLR in crook lying
mal and necessary for a healthy spine, and that it is
• pelvic rocking in crook lying ( i.e. arching and
rounding the back)
possible to improve • areas of hypersenstivity in the feet; a graded
touch/massage programme to address this may be
• lumbar rotation i n crook lying ( Le. tald ng both legs
to one side then the other) • essentially normal neurological l1ndings, e.g. reflexes
appropriate at some stage. Note that findings Lil<e normal reflexes and diffuse low
• taking some exercise, e.g. swimming, walking.
grade alterations in sensitivily that are out of classic nerve root or nerve trunk patterns increases confidence
Find ings that may be focussed on fo r
in the therapist's structural and physiological interpret
improvement
ation. It also downgrades notions about mechanisms relating to anatomical structure, such as tissue integrity or peripheral nerve root vulnerablility. Also note that in the lying examin ation a 70 degree SLR with foot dorsiflexion adding to the symptomatic response could be seen as a positive sign for neurody
Much relates to fear of movement, fear of damage and fear of pain exacerbation, as well as l ack of use and physical deconditioning: • winCing and holding with many movements and
activities
namic abnormality or a peripheral neurogenic mech
• unable to go to all fours or get down onto floor
anism. However. I hesitate to consider this anything
• markedly reduced lumbar motion in standing and
more than hypersensitivity relating to the neural con
during functional activities. e.g. dressing
tinuum and central processing, rather than labelling it
• hypersensitivity over back/buttock a nd feet
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5 UNNECESSARY FEAR AVOIDANCE AND PHYSICAL INCAPACITY IN A 55-YEAR-OLD HOUSEWIFE
somatic perception using questionnaires. for example
• heaviness/weakness in arms/neck/legs • poor balance
the Modi fied Zung Depression Inventory and the
• poor hip movements
Modifted Somatic Perception Questionnaire (MSP Q ) .
• general lack of end-range capability in affected areas
H i g h scores o n these measures really indicate that
• giving way with muscle testing.
there may be a need for psychological input alongside
R'Camples of some important rUDctional findings (acti vity and participation restric tions):
the physical rehabilitation process (Waddell. 1 9 98).
• Clinical
• decreased tolerance to standing still
reason i ng commentary
The continual linking the clinician mal<es between
• decreased tolerance for sitting
examination Ilndings and implications again high
• decreased walking d istance
Lights the dynamic nature of clinical reasoning.
• not dressing independently
Expert therapists do not wait until aU possible exami
• inactive in the evenings
nations have been completed before lorming and fur
• sleeping problems
ther testing hypotheses. Hypothesis generation and
• limited shopping • stopped various activities. e.g. driv ing. cooking.
gardening. nower arranging. embroidery
testing is a n evolving process commencing from the patient interview and continuing through the physi cal examination a nd ultimately throughout the
• general feeling of weakness and being unfit.
ongoing management. While expert therapists will
Social participation restrictions include:
have highly developed knowledge bases that enable them to recognize clinical patterns and management
• entertainment and hobbies curtailed/ n i l
implications. they arguably only reach that level of
• not been o n holiday • a significant loss from what she used to do (see
list above)
knowledge organization through a process of retlec live reasoning that allows them to integrate acquired biopsychosocial knowledge with clinical presenta
Mental/psychological impairment was not fo rma l ly
tions learned from their practice. Even management
evaluated. However. it is quite clear that this lady is
in the form of deliberate responses to the patient and
distressed and rr ustrated by her predicament and is
goal setting are seen to commence within the physi
desperate to get help in some way.
cal examination by this expert. a skill only possible
Many
chronic
pain
management
units
assess
levels of depression and distress as well as heightened
when the therapist is able to think sinmltaneously and metacognitively on these different planes.
The steps that follow encourage a patient domin ated role i n the process of restoring physical fitness and confidence. Patients usually quickly understand There are two initial difficulties that need to be help fully addressed. Both relate to the patient's beliefs. First. the beliefs about the nature of the problem are very 'vuln erable/weak structure' and disease orientated. Secondly, the beliefs about treatment are orientated towards a process of finding the source or disorder and
the meaning of a deconditioned state and that lack of physical activity leads to loss of physical fitness and heig htened sensitivity.
Edu cation 1 The overall goal of the first 'education' input was to
fIXing or curing it. Lara seems to have high expectations
decrease her concern about pain me aning damage or
that I will provide her with the cure and this is unreal
da nger. so that the process of gradual return of phys
istic and unhelpfu l.
ical co n fidence might go ahead less hindered by nega
A primary goal was to shill her understanding of
tive and fe arful thinking about structural damage and
the problem from a perspective where pain is seen as a
progressive disablement. This is not as easy to do as it
reliable guide to danger (adaptive/helpful pain) to one
sounds. Malada ptive pain is ju st as real as adaptive
where pain can in large par t be viewed as of l i ttle value
pain, and i t can be very h ard to believe that the hurt
(maladaptive/unhelpfu l pain).
you have has l i ttle meaning or little value. Lilce i t or
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CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXP E RT MANUAL T H E RA PISTS
not. patients are more likely to listen to and believe clinicians who in their minds have some kind of higb professional status. The second aim was to help Lara to understand that a passive treatment approach was inappropriate at this stage and that the best approach involved a great deal of input from her. Part of this involves a shift in emphasis from pain-focussed management to more function-focussed goal achievement. Education. therefore, involved a simple brief discus sion of the following. The nature of adaptive/acute pain and chronic/ maladaptive pain: the former is useful , helpful pain as opposed to useless. unhelpful pain. • A simple explanation was given for maladaptive and excessive sensitivity to movement, intolerance of prolonged posture, and tenderness/hypersensi tivity to touch and pressures. • The analogy was made of ongoing background pain to an annoying tune in the head all the time. i.e. the constant pain relating to abnormal nervous system 'circuitry activity ' rather than a disease or abnormality in the tissue where the hurt is felt. Explaining and discussing phantom limb pain often helps here (Gifford 1 998a. b). • The gate control theory of pain is explained (i.e. that pain normally comes and goes relative to an individual's attention and the value or meaning they may put on it). •
Reduced activity
/ ! /�
UPhOP' ' '"'" 9 h" ,"d b
Chron i c Pain '
T
The effect of mood on pain, activity and life in gen eral is discussed. This helps the patient to come to terms with low mood being normal for anyone who suffers an ongoing and seemingly non-resolvable problem. It also underlines the positive message that mood state commonly improves as the patient starts to achieve progress and gradually recover better physical function. • The effect of 'pain fear' and 'damage fear' on move ments, activity and life leads on to introducing a treahnent approach with a locus more on functional recovery/physical confidence rather than on getting rid of the pain or the apparent source of the pain. Patients somehow have to come to terms with the fact that pain therapies and medical interventions for chronic ongoing maladaptive pain have a very poor record of success. In contrast, approaches that focus on better physical confidence and fitness have a much belter record. ft is sometimes helpful to give a brief history of another palient who bas been successful. Giving the patient a book like Neville Shone's Coping Successfully with Pain ( 1 995) is often very helpful. • The illustration from Nicholas ( 1 996; Fig. 5. 2) was used to show the patient the way in which modern pain research has begun to appreciate the com. pJexity and difficulties that a patient with ongoing pain can have. Patients are often relieved to find that medicine is beginning to understand the impact that their ongoing pain has on their lives. and that they are not alone.
•
� �� �
•
j
\
P hysical deterioration (e g. muscle wasting,
'''"P e ss, JOint stlffness)
Repeated treatment ___ Feelings of depression . .
_
helplessness and Irritability
(failures)
Long-term use of pain killers and sedative drug S'dc o
Excessive Suffering
L /
(e.g. stomach problems lethargy, constipation Loss of job. financial and family stress
Fig. 5.2
--'
_ _ _ _ _ _ _ _ _ _ _ _ _ _
The common consequences of chronic pain. (Red rawn with permission of the
IASP. from Nicholas, M . K . (1 996).Theory and practice of cognitive-behavioral p rograms. In Pain 1 996: an updated review. Refresher course syllabus. Campbe l l . J . N ., ed., pp. 297-3 03. IASP P ress, Seattle.WA.)
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5 U N N ECESSARY FEAR AVOI DAN C E A N D PHYSICAL I N CAPAC ITY IN A 55-YEAR- OLD H OUSEWI FE
Lil<.e many si milar patients. Lara fou nd the inlormation very enlightening and interesting. She had many ques tions. and we both explored many issues that related to the hopes and lears of past management as well as issues for the fu ture. She quickly grasped the concept of maladaptive pain and that physically getting back more relaxed and normal movements would be a good start ing point for recovery. She was insta ntly eager to start the physical 'chaJ lenge' and we spent q u i te some time dealing with fear of bendinglnexing the spine and the natural stTCngth of the spine. even when degenerate. As with so many patients in s imilar situations she said. 'Why hasn't anyone told me th i s before about pain and movements?' An answer that can helpfully be given is that. ' I l is o n ly in the last 1 0 to J 5 years or so that science and research has started to give us a better understa nding or pa in. and it is only very recen t ly that the fu ll implications for management of pain has started to have an impact on clinica l practices'. This attempts to avoid producing any unhelpful anger with previous practitioners and treatments or advice. Pre-prepared handouts were given relating to all the above.
Baselines, pacing and incrementing Most pain sufferers like Lara persist with activities until they are forced to stop by the pain. This often i nvolves many hours. sometimes days of resting and i nactivity. In order to breal( this overactivity-underactiv ity cycle, exercises and activities are paced so that this very u nproductive p rocess is overcome. A base l ine is the number/repetitions/amount of time for an exercise or activity that a patient can manage to do every day regardless of the intenSity of the pain. This is found by taldng the average of a series of trials done over several days and then reducing the average by 2 0%. Incrementing or pacing from this baseline is done by increasing the number or time of each activity / exercise after a set period. for example weekly or every fou r days (Harding, 1 9 9 7 , 1 9 9 H : Shorland. 1 Y 9 X ) . The overactivity-underactivily cycle was explained and pacing o f resti ng was d iscussed. Exercises were recorded for reference and handouts were given relating to exercise and functional pacing and the overac tivity underactivit')' cycle. The follOWing exercises were used: • crook-lyi n g starting pos ition: pelvic rocking:
l u mbar rota tion;
a l tern ate leg Jlexion
(pOSSibly
progress to grasping knee or if easier do i n sitting
Starting the process
as in examination)
The last 45 minutes of the second consul tation i nvolved a focus on a series of simple exercises rela ting to the back. hip and leg. as well as two fu nctional activi ties:
• active SLR w i th non-act ive leg in crook positi o n • waU<ing up/down s t a i r s o r step-ups (whi chever preferred)
waLldng and going up/d own stairs. Concepts discussed
• sit to stand
included gradual mastery (graded exposure), baselines,
• stand i ng
pacing and incrementing the exercise programme.
starting
pos i tion
( w ith
support
as
required): hip Jlexion/extension, h i p abducti on, one leg balance, a l te r nate calf raises
Gradual mastery/graded exposure process The term gradual mastery/graded exposure comes [rom the psychological li terature dealing with phobias
• tip-toe i n g
practice
(wei ght
through
a r ms
as
requ ired ) . Instead of waU(ing for 2 miles i n termittently a n d w i th
(Harding, 19 9 8 ; Shorland, 1 9 9 8 ) . The key process
marked exacerb ation, it was decided that a short reg
is that the patient overcomes their rear (ror example
ular walk of good quality would be of greater benefit.
of a spider or or a particular movement) by gradually
La ra's i n i tial task was to find a reason able baseli ne
approaching rather than avoid ing the cause of the fear.
starting ti me or d i stance that would not i ncur a
This can be a very slow process and the speed of expo
massive Oare up and which was m a nageable even on
sure is determi ned by the patient rather than by thera
bad days.
pist bu llying! A successful outcome is achieved when the process is graduated (slowly more and more dimcult levels are mastered), repeated regularly and prolonged.
Management stage 2
Gradually, tbe patient gains confidence and learns that
Lara returned 2 weeks l ater. I saw her hoVice over 2 days,
their fears are unfounded as they achieve their goals.
w i th each session being 1 . 5 hours.
The key to success is starting the chosen movement or activity at a realistic and achievable baseline.
She rel t she had begun to maste r lumbar move ments in lyi n g (e.g. Oexion using pelvic rocking and
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CLI N I C AL REASO N I N G IN ACT I ON : C ASE STUD I ES FROM EXPERT M A NUAL THERAPISTS
single leg flexing) and paced up her numbers from a n
thrown in from me, she came up with the notion of
i n itial baseline of 1 0 slow, relaxed, small-range repe
doing it while lying in the flexed pelvic rocking posi
titions to 1 5 fuller range and sligh tly faster repetitions.
tion. The result of this is that it helped her to find a
She had managed to generalize this out to modest flex
way of doing the exercise much more comfortably,
i n g in sitting and was feeling good about it because
but it also introduced the idea of being ' allowed' to
she was needing quite a bit less help with dressing
play around with or modify an exercise to make it
from her husband. She made a spontaneous comment:
more acceptable. For so long patients h ave been fear
'The most profound thing that has happened is the
fu l of doing a n exercise 'wrong ' . In my opinion . this is
sense of relief. I believe what you say; it makes sense.
very unhelpful when dealing with this type of patient
It gives me control and it allows me to have a vision of
and problem.
my life with some kind of fu ture. Whatever it is going to be it will be better than where I have been for so long-I know that . ' S h e had had o n e bout of a very bad flare u p for 1 day but had managed to keep most of the programme going. For the first time. the flare up had not unduly
Some new exercises were added: • sit-up i n supported (pillows behind back) slouch
Sitting • lumbar extension i n lean fo rward sitting with arms
supported on knees.
bothered her. Her comment was, 'It taught me that
The first was decided on after experimen ting in differ
my desire to progress quickly may be my worst enemy.
ent starting pOSitions to get some dynamic abdominal
The day before I got carried away with the exercises
work going and to encourage active lumbar flexion.
and paid for it. The good thing was that I recovered and
Lying l1exion from the 'top-end' was found too d iffi
haven't lost any ground.'
cult. Bilateral leg lifting from the crook-ly ing position
She found the use of regular short resting far more
produced s harp pain in the initiation phase of the
effective than responding with rest only when pain
movement, but reaching forward from a gentle slouch
became severe and unmanageable.
sitting pOSition was enjoyable! This was because, first,
The second half of the first session was spent going
she found it rewarding to try slouchi ng after so long
through some of the things looked at in the in itial
avoiding it and, secondly. the movement was pain -free
physical examination. Movements and the exercises
and easy to perform. Lara could immediately see how
she was doing were observed and discussed, a n d
her abdominal muscles were working quite strongly.
walking, climbing steps, balance e t c . were reviewed.
that she was flexing her back, and that she could
The focus was on patient comments about the quality
occasionally try a lying, or half lying, sit-up when ready
and feel of each task/movement, not o n pain and not
to progress.
o n any ' therapist opinion' about the movement
Sitting with arms supported on knees was the
( u nless helpfu l ) . At appropriate times, positive rein
star ting position fou nd most useful as a progression
forcement was given. DiffIculties were discussed and
from extension in the crook lying position. It should
Lara was encouraged to problem solve and find out
be remembered that Lara ' h ated ' extension from the
for herself rather t ha n be told or shown alternatives
standing position.
by me. For example, she had found left SLR in crook lying difficult and uncomfortable to do. She had kept to a baseline of four repetitions three times per day but had not progressed it and did not like doing it much as she immediately felt sore in her leg and back. I explained that the exercise strengthens weak hip
and back muscles, as well as moving a nd stretching leg muscles and nerves from the back. Also, that sub tle adjustments of the back, the leg or the starting position were often helpful in making movement eas
Education 2 In the second half of the session, time was taken to explain the importance of setting realistic goals in all areas of Lara's life and looking at the physical compon ents that needed to be mastered in order to achieve these goals. The following goals were chosen and pro grammes worked out to help to achieve them:
ier. I gave an example of doing the exercise in a semi
• dreSSing independen tly
reclined position. She tried it and was not convinced.
• getting on all fours
She then tried it sitting but fou nd this even harder.
• swimming one length of the pool
After 5 minutes or so experi menting, with some ideas
• starting hobbies again (e.g. 110wer arran ging) .
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5 U N N E C ESSARY FEAR AVOIDANCE AND PHYSI CAL I N C APAC I TY I N A 55-YEAR-OLD HOUSEWIFE
The health re q u i rements of tissues
progressing the swimming and could now manage
Some si m ple informati on was required about the needs of' musculoskeletal and neural tissue for move ment and exercise to remain healthy and to improve fitness. Part of this included the notion that fitter tis s u es wh ich are used in a confid ent way have a b etter chance of becoming less sensitive. Key aspects of tissue req u i rements includ e th e need for regular through range movements. comfortable stretching. progr essive strengthening. endurance training. and im proved coord ination. A handout was gi ven to Lara .
two lengths of the swimming pool wit hout a signill cant O a r e-up. She had star ted som e simple gard ening tasks as well as getting more i nvolved in some or her hobbi es. M ovement
quality
a nd
range
was
markedly
improved. For exam ple. she was able to get onto the Ooor and as a result now managed to get in a nd out or the bath. She was manag i ng a few haJ f sit-up exer cises a nd had increa sed her d a i ly walking to a com fortable 20 mi nutes. She had progr essed to d oi ng a full SLR from supine lying. Time was spent d i scussing some new goals. These
Und erstanding th e m u ltiple facto rs that can
included
trigger pain
enter ta i ning her family to a
meal and
the possibility of a holiday for a few days with her
Headaches were used to illustrate the multiple trigger
husband .
ing factors that can be involved in triggering pa in.
Some current d ifficulti es were d i scussed. In particu
Most pati ents are able to come up with some of the fol
lar this included a ma jor concern she had abou t the
lowing factors that can trigger or worsen a heada che:
pa i n and the hypersensiti vity: 'I am d oing so much
d iet. tired ness. stress and tension. a parti cular envir
b etter physically. I am achieving more. I continue to
onment or situati on. as well as more physical factors
improve a nd my confidence is gradually returning, but
lUee prolonged postures or overexer tion when tired or
the pa i n and symptoms seem to be much the same a nd
hungry. These issues are then d i scussed in relationship
I am stUl very tender.' This prompted a review of the
to the variability of the patient' s pain and in such
a
nature of chronic pain and hypersensitivity. but a lso
way that th e patient can start to und erstand the com
a review of pain reduction a nd d esensitizing strat
plexity of the problem and the cli ffi culties in trying to
egies that may be helpful. Some of these were the use of
relate the waxing and waning of pain to a single struc
rest and relaxation techniques, progressi ve d esensitiz
ture or pathology. RealiSing that multiple fa ctor s are
ing ma ssage. heat/cold, 'nice' exercises and stretches.
often i nvolved in precipitating Oare-ups helps the
'Nice' exerci ses are those exerci ses that the patient
patient to realise that there is more to pain and its
chooses which feel good and are often u sed to ease
behaviour than j ust physi cal factors.
d i scomfort: they are usually a combination of relaxed through-range exer cises a nd comfor table stretches. A simple breathing relaxation technique was ta ught
Management stage 3
and instr uction gi ven regardi ng the use and progression
On month later Lara retur ned again ror two more
of massage over the tender areas. Agai n , information
long sessions. She had achi eved all the goals and was
was written d own and hand outs gi ven.
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REASONING DIS CUSSION AND C LINI CA L REASONING COMMENTARY
The abdominal exercises you have described appear ver y general. Do you feel assessment of
• Clinician's answer
specific trunk and pelvic muscle function ( i.e.
This is a very personal ma tter, especi aUy conSidering
awareness, recruitment, strength, endurance,
the current wave of enthusiasm for speci fic muscle
etc. ) is appropriate for this sort of presentation,
control a pproaches. I would urge great caution i n over
and if so, at what stage would you assess these
focussing on specific impairments at this stage. Muscles
further?
work i n groups. a nd movement should normally b e for
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C L I N I CAL REASON I N G I N ACT I ON: CASE STU D I ES FROM EXPERT MANUAL TH ERAPI STS
the most part unconscious. thoughtless and silent: this
matter and one that is really very difficult to pred ict.
is what needs to be rehabilitated. Recall that Lara had
Everyone wants their pain to go: however, the reality of
been given specific exercises for the trunl, and pelvic
long-term well-established widespread pain with its
region in relation to a diagnosis of 'instability' and had
underlying neurophysi ological representations is that.
been told never to bend without tightening her stom
IU,e the signific ant memories of our lifetime. they are
ach. This style of approach may enhance somatic
very hard to get rid of or forget. The reality is that the
awareness as well as i ncrease fear that i.f she does not
pain wi l l probably always be there: however. many
do this she is W,ely to cause further harm. If success
patients like Lara find that it bothers them less and it
fu l fu nctional recovery occurs then bringing more
becomes easier to manage.
focusseD 'muscle imbalance' issues in may be worth while later on. It is always important for a patient to feel that they have good muscu l ar control. especially around an area that has given a great deal of trouble for a long time. However. I do not thi.nk that it is desir able for patients to have to recruit muscles consciously before or during movements: not only is it very di.fficu l t to d o for many people. i t i s n o t natural.
Clinical reasoning commentary 'rhe application of any t herapeutic interven t ion . be it joint mobilizati o n . motor control retra ining or explanation to alter understanding. must be based on patients' un ique clinical presen talions. Recipe
What are your thoughts regarding this patient's long-term prognosis? Please include some reference to the 'positive' and 'negative' features in her presentation that you feel assist in predicting this result.
treatments or protocols are unfortunately s t i l l common in m a n u a l t herapy. a l t hough oft en the lalest 'fad' is created by those who extrapo late from thc ideas of others and n o t by the originators of the research on which i t is based. There is clearly a continuum of impairment possible within the sensory-motor system. whic b , when considered along with the multitude of biQPsychosocial fac
Clinician's answer Lara has successful ly coped with a new perspective on her problem for over a year. She has made quite sig nificant gains in function and independence and has reintroduced many of her former hobbies and inter ests. This was a l l he lped by her open-mindedness. her readiness to accept new perspectives on her problem, and her eagerness to take responsibility for her own management. Her home situation and fi nancial secu rity were very helpful in that they a ll owed her to h ave time to devote to the programme. She got involved, she did the programme and she worked hard at i t . Note h e r comment above that ' worki ng w i t h chronic pain can be very hard work ' . I n this respect, it is very common for patients to make changes to t heir lives. manage well for a while, but to then relapse i n to old ways and become passive and despondent about the whole s i tuatio n . Lara is as vulnerable to relapse as aoyone and this is a strong possibil ity. Her long-term prognosis looks good. Importantly, there are two aspects to consider for the future: her dis ability and fu nction and her pain and symptoms. The prognosis for fu nction is good. Her recovery is already excellent and still improving; even if she relapses she knows the way out. Symptom prognosis is a differe nt
tors that influence how that impai rment will man ifest in
it
given patient. necessitates that therapists
are sufficiently open-minded and skilled in sensory motor retraining. While a variety of techniques are used to facil itate improved motor con t rol. it is important the underlying strategy is based on sound principles of motor control and learning theory. Again there is no recipe. Even with the growing body of resea rch to assist us i n recogniz ing the factors that i n n llence motor control . appli cation of that knowledge to our patients requires advanced assessment and teaching/training skills as well as the clinical reasoning to know which stmte gies are indicated and when they should be trialed. Reassessment of the effect on the differen t systems (e.g. psychological. cognitive/affect ive/behavioural. neuromusculoskeletal) should guide the progression and modil1cation of a l l interventions. Determination of prognosis may well be one of t he most diffic u l t decisions for therapists to make. However. prognosis. l ike the other categories of hypotheses. forms patterns. A t tending to the posi tive and negative features fr0111 the patien t ' s psy chosocial and physical presentat ion is the key.
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S U N N E C ESSARY FEAR AVO I DA N C E A N D PHYSIC A L INC APACITY IN A 55-YEAR-OLD HOUSEWIFE
There may also be more t han one prognosis. as d is
but. as time goes by. and particu l a rly if the prog
cussed here. with different prognoses predicted for
nosis is not met. taking the time to relled "vhat may
the patie n t ' s functional l'ecovery and pain recovery.
h ave been missed. over- or u nder-rated i n the i n itial
The crucial factor. as with all clinical pat t erns. is
j udgment, so that future pred ictions might be
reflective reaso ning. Not simply making a prognosis
improved .
I picked Lara as a good example of the problems we
•
a l l can have w ith the management of chronic pain One year a fter Lara first consu lted me she was back to near normal levels of activity a nd conl1dent that she would progress fu rther. She moved in a relaxed way and was not frightened to bend her back. She could easily bend to touch the floor with both hands nat: she could walk happily on tip-toes and go up stairs two steps at a time. She sti l l had low periods and occasional pain Ilare-ups. Her pain level overa l l was. in her words. 'more manageable and less intrusive ' . She slept much better and man aged slowly to stop a l l her medication. She commented: ' Worki ng with chronic pain can be very hard work. it is a daily cha llenge that most o ften is quite conquerable, b u t on some days it is a long and very tough and tiring struggle ' . At the time o f writing, there h a d been seven visits in total and s he was coming to see me about once every 3-4 months. There had been no passive treat ment, but there had been a great deal of s k i lled phys ical appraisal and the gradual i n troduction of more and more specil'ic exercises related to more minor physical impairments. This is not always required but it had been Lara's aim to get as fit as her age and underlying condition would allow.
states. She ex hib its many features that can b e made to I1t various models a n d explanations, yet if her prob lem is really scrutinized there is a great deal that does not I1t. can be viewed as odd or can be u n productively classified in some way as ' n o n-organic'. She had been through a large number of therapies and consultants i n search of a n a nswer to her problem with little suc cess. She has been through periods of great hope with some of them, yet her hopes d windled to despair as treatment after treatment failed and consultant a fter consultant provided inadequate or even d ismiss ive explanations and attitudes to her and her problem. LU(e many chronic pain sufferers, Lara had wide spread symptoms and signs that do not I1t into neat diagnostic categories or syndrome presentations. She had many maladaptive movement and behaviour pat terns, and she had many unhelpful and u nrealistic beliefs and attributions about the n ature of her problem and the means of recovery. Her case history illustrates how an enclosed tissue-based and predOminantly pas sive approach to treatment really did not help, and how a multidimensional and multilevel perspective and approach enabled her to recover and lead a far fuller and more confident life .
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Copyrighted Material
CHAPTER
A chronic case of mechanic's elbow Toby Hall and Brian Mulligan
�
SUBJECTIVE EXAMINATION
Howard is
normally healthy 51-year-old male who
c o r t isone injections i n the region of the right lateral
ha s a sed en tary l ifestyl e . He is right hand d omi na n t and
epicondy l e near the common extensor origin . This had
a
enjoyed the occasional game of Imvn bowls prior to the
no e ffect in red u c i n g the s y mpt o ms and o n l y i n creased
onset or his elbow p ro b l e m. He runs a smal l motor vehi
his p a i n lor 48 ho urs after each injectio n.
cle
repair shop
attached to
a
se rv i ce station. He usually
manages the business. but for 2 weeks be had to stand in
lor one of his mechanics who was
aw a y
on sick leave.
The principal natme o f the reliel' work invol ved fit
Chronic stage At this s tage, Howard was having proble ms writing
ting new exhaust sys tems . The majority of tasks were
and using
undertal,en in a vehicle ins pection pit with the car over
doctor to a rheumatologist, who ordered a bone scan.
head. Howar d noticed the sudden onset of right elbow
The results o f the scan were normal, w i t h an app ar
a
computer at work He was re ferred by his .
pain at the beginning of the second week of rel ief work.
ent coincidental finding of i ncreased tra cer uptake in
On this particular day, he experienced extraordinar y dif
the C5-C6 and 1'3-T4 facet
lkulty loosening
patient was then advised to see a phy siothera pist fo r
a
corroded nut using a socket wrench,
with considerable force being required. Within an hom, he became
aware of moderate lateral elbow p ain with
any forcel'ul
j O in ts b i l a terally. The
s treng thening and s tretching exerc ises. There was no previous history of arm problems des p i te the fact that Howard had been a motor
the rest of the week as h e was unab le to restrict his activ
mech a n i c for 15 years of his \Norking life. However.
ity because there was no replacement. The pain gradu
th ere was a h istory of recur rent neck p a i n for which
ally increased to the point of becoming quite severe. In th e following week, be returned to his normal duties, which mainly involved supervising mechanical
he h a d never s o u g ht trea tment. These ep isodes were c aused by lo n g periods working u nderne a t h ve hic l e s
,
the last being 3 years ago.
wo rk and office duties. The pain continued to bother
At initial ev al uati on 4 months a fter the o n set of
him constantly but had subsided to a moderate inten
symptoms, the p a tient complained of pai n in the
sity. Being a busy person, he let the situation continue
a nterol a teral and posterolateral aspects of t he elbow
lor a
further 2 weeks . He then went to see his general
medical practitioner, who prescribed non-s teroi dal anti-inflammatory d rug s for 4 wee ks
6.1). There was no pain or o ther symptoms else
Duri n g this
There was no apparent stress in Howard's life and he
constant to
was coping well "\lith his problem . He h a d continued to
intermittent nature. The doctor the n , over a period
work a n d on questioning there were no work or f a mil y
period, the pain began to change from an
(Fi g.
where in the left or right upper quarter.
.
a
of 8 weeks, administered a series o f th ree local
issues that might have interfered with his recovery.
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87
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
Fig.6.1
� I Jo
Body chart indicating the extent of elbow pain.
R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R E A S O N I N G CO M M E N TA RY
How did you interpret the effects of the
change. Cortisone is a po w e rfu l anti-inflammatory
medical interventions on the patient's
agent: if there was any remaining inflammation
symptoms!
some relief of sympto ms would likely have resulted. It has been demonstrated that in chronic tennis
• Clinicians'
elbow (also known as lateral epicondylitis or lateral
answe r
The patient report ed
epicond ylal g ia) there is histological evidence of angio
gradual change in the nature of
fibroblastic hyperplasia (Nirsc h I and Petrone, 1979)
his symptoms during the 4-week period when he was
and mesenchymal transformation ,vithin the common
taking non-steroidal anti-inflammatory medication.
extensor tendon at its pOin t of insertion into the lateral
a
Sarkar, 1980). In contrast ,
He felt that his sym ptoms changed from b ein g con
epicond yle (Uhthoff
stant to intermittent. This improvemen t may have been
there is no evidence of acute or chronic inflammator y
related to spon t aneous recovery of the disorder rather
cells. Prolonged anti-inflammatory m edication or
and
than the prescribed medication, especially as he had
cortisone injection are, therefore, unwarranted in the
stopped the activity that had caused the symptoms
management of chronic tennis elbow and were (as
in the first place. There may have been an inflamma
would be expected) u ns u cce ss ful in this case.
tory element to the co n dit i o n , arising from repetitive micro trauma through ove r use and the sudden exer tion (overload) required to loosen the corroded nut. This inflammatory component subsided with time and with the aid of the anti-inflammatory medication. The symptoms rem a ining after the 4-week period were pro b abl y related to mechanical dys func t ion of
D
What were your initial thoughts and hypotheses about the possible source ( s ) of the patient's elbow pain!
• Clinicians' answe r
the elbow complex. The patient reported a temporar y
In this case of localized pain in the region of the lateral
increase in pai n after local cortisone injections in
epicondyle, possible structures/pain sources to be con
the region of the lateral epicondyle, but no overall
sidered include local joints, musculotendinous elements
Copyrighted Material
6 A CHRONIC CASE OF MECHANIC'S ELBOW
and neural tissue, as well as remote structures, par
or inl1ammatory cells in chronic tennis elbow (Nirschl
ticularly within the lower cervical spine, Working
and Petrone, 1979; Uhthoff and Sarkar, 1980) and
hypotheses in order of priority were:
the patient's poor response to powerful local anti
1. The insertion of the wrist and Unger extensors
at the lateral epicondyle, notably extensor carpi
radialis brevis 2, The nervi nervorum supplying the radial nerve or
its
terminal
branches
(posterior
interosseous
nerve)
inllammatory agents, it would appear that inflamma tory nociceptive pain is an unlikely explanation for the ongoing symptoms. The pathobiology of tennis elbow has been pro posed to involve a tear of the tendon of origin of the extensor muscles from the lateral epicondyle (Cyriax,
1936: Nirschl and Petrone, 1979). The tear occurs at
3, The lower cervical spi n e (C5-C7)
the junction between muscle and bone, and healing is
4. The radiohumeral and radioulnar joints.
slow because of a lack of periosteal tissue overlying
The evidence in support of local structures includes a
this bone area (Putnam and Cohen. 1999). It has been
well-defined area of pain , without evidence of associ
shown that the granulofibroblastic material laid down
ated proximal or distal symptoms; a history of abuse of
in the repair process contains free nerve endings
local elbow structures immediately preceding the onset
(Goldie, 1964). Repetitive microtrauma from overuse
of symptoms: activity involving local structures repro
or abnormal joint biomechanics may overload the
duced the symptoms immediately after the symptom
repairing tissue, mechanically distort the scar tissue
onset: and an unvarying area of symptoms over the
and thus stimulate the in situ free nerve endings
history of the condition. In support of contractile and
sulTiciently to evoke mechanical nociceptive pajn.
associated elements as the most likely pain source is the
ChroniCity of the problem may be related to continued
history of excessive muscle force required to release a
use of the arm. causing repeated microtrauma to
corroded nut. The evidence against local structures
the scar tissue. which has not yet gained adequate
includes tbe failure of local cortisone injections to relieve pain. although it is highly likely that this relates to the lack of an inflammatory process rather than
strength to withstand normal function. In the case
injecting the wrong tissue.
tendinous overload , either by repetitive microtrauma
history, there is some evidence to support this hypoth esis, The history of onset is consistent with musculo
At this point there is little evidence to support
or sudden strain. The pain has changed from a con
remote slructures as a source of pain, other than a
stant to intermittent nature and is related to activities
tenuous link with the bone scan abnormalities at
(such as keyboarding and writing) that involve repeti
C5-C6 and T3-T4, as well as a history of stressful
tive use of the proposed damaged musculotendinous
cervical spine postures working underneath cars.
insertion.
Furthermore, there is no complaint of neck symp
Alter natively, it has been suggested that ischaemia
toms to suggest somatic referred pain from cer vical or
plays a part in the pain process (Putnam and Cohen,
thoracic structures, nor dysaesthesia or sensory loss
1999). The blood supply to the muscle origin is
to support cervical neural compromise.
limited and it is suspected that it would be prone to reduced flow after injury (Uhthoff and Sarkar, 1980). Ischaemia can cause nerve endings to lower their
What were you r hypotheses regard i n g the
thresholds for firing (Gifford and Butler, 1997). The
pathobiological pai n mechanisms involved?
nerve endings may then nre more readily and with
What evidence was there to support (and
movements
negate) your hypothes is?
• C l i n i c i ans'
no
t normally painful. The patient's age
is a Significant factor in reduced vascularity of the musculotendinous insertion .
answe r
At this point in the examination, there is little
In this case, the condition is certainly chronk. being
evidence to support a neuropathic disorder involving
now 4 months in duration. If we assume that the ori
abnormal nerve conduction, central nervous system
ginallissue damage was a tear of the musculotendi
changes or maladaptive behaviours. Certainly, there
nous insertion related to forcing the corroded nut,
do not appear to be any significant psychological or
then this soft tissue damage should normally have
social issues that could contribute to a central pain
repaired by this time. C onsiderin g the lack of evidence
state.
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C L I N ICAL REASO NING IN ACTIO N: CAS E STUDIES FRO M EXPE RT MANUAL T H ERAP ISTS
• I
• C linical reasoning commentary
attended to carefully. as have 'missing features'
The response to Question 1 nicely demonstrates
features that would be expected
with
a
or
particular
how hypotheses relating to pathobiological mecha
clinical disorder. such as the absence of neck symp
nisms (notably tissue-healing mechanisms) have
toms with the hypothesis of somatic referred pain
been ge nerated early in the clinical encounter and
from cervical or t hora cic structures. Whereas the
that tentative decisions are being formed at the out
novice clinician often ignores features that do not lit
set. rather than at the end. of th e examination. It
with the favoured hypothesis. the expert clinician
is also evident that. the integration of propositional
avoids this error and weighs bot.h the supporting
knowledge of pathobiological mechanisms within
and negating evidence
the broader knowledge base of the expert clinician
objectively.
These two hypothesis categories are not each
e n abl es the consideration of this patient's clinical
considered in is olati on
presentation in
intricately intertwined. and consequ.ently have an
the light
of
research-validated
but rather are found to be
impact on the deciSion-making process proceeding
theory.
A Dumber of hy potheses relating to the struc tural s o ur ce s of the elbow p ain and related
pat hobi
in relation to the other h y pothe si s category. This is rel1ective of
a
richly organized knowledge base that
ological mechanisms (both tissue healing and pain)
is deep as well
have been generated from this patient's history thus
clinical reasoning of the
far.
with ranking of
these hypotheses evident.
as
bro a d. and is characteristic of the
expert clinician.
fn addition. there is evidence of attention to the
Testing of these hypotheses is apparent in that con
possibility of psychosocial factors (yellow. blue and
sideration has been given to the supporting features
black flags: see Ch.
in the patient's presentation. [mportantly. however.
contributecl to the patient's p a i n state and created
non-supporting clinical nndings have also been
obstacles to his recovery.
Pain behaviour
I). which potentially could have
llexed as he did using
a
writing pen in the
same
principal aggravating activities were writing for more than 10 minutes and use of a co mp u ter keyboard for more than 15 minutes. The pai n never
position.
stopped him undertaking the activity. but at the end
if he slept with his elbow llexed
of a busy day involving these activities. his elbow pain
tucked under the pillow. In the morning he generally
would not settle until the fol l owing day. Gripping
awoke pain-free and without elbow stiffness. unless
and squeezing activities (including carrying heav y
he had been sleeping with his arm in an awkward
The
objects in the right han d ) were
also painful. For this
Howard was un a w a r e of any position or activity that wou Id ease his pa in. His sleep was on ly disturbed
and the forearm
pOSition during the night. Specific questions regard
and sustained
reason he had stopped playing social lawn bowls
ing the effect of cer vical movements
for the duration of his symptoms. He also described
cervical postures p rovide d no further information.
occasional pain when bru shing his teeth or shaving.
Specific questioning regarding general health. pre
as he had the same difficulty holding and manipulat
vious medical history and other related health issues.
ing a toothbrush/disposable razor with the elbow
revealed nothing apart from dermatitis.
rt1 D
REASONING DISCUSSION
Did you specifica l ly screen fo r o r appraise the patient's psychos ocial status (i ncluding h i s
u n d e rsta nding of the probl em and his feelings
• Clinician s'
answer
In response to the question of what was his main
p atient answered that it was pain in the
abou t his management to date and the effect it
problem. the
is hav i ng o n his life)? Did th is factor have an
region of the lateral epicondyle when writing or
effect on his symptoms?
using the computer keyboard. The patient had never
Copyrighted Material
6 A CHRONIC CASE OF MECHANIC'S ELBOW
before been to a physiotherapist for treatment. His
burdened by his elbow disabil i ty He believed that auto
only reason for attendin g was because he had been
mechanics had to put up with some impairment dur
asked to do so by his treating d octor. His un derstand
ing their working life as a consequence of the physical
.
ing of the problem was ba sed on what he had been
nature of their work. His previous hist ory of neck pain
told by the doctors he had consu lted in that he had
bore witness to this fact.
.
Howard appeared q uietly resig n ed to his lot. He felt
tendinitis of the wrist and fmger extensors. The elbow p roblem certain ly affected his life. He
that medical management had not really h e l ped him
had pain through the day at work and was unable to
and that he was p robab l y going to have to live with
perform his normal duties of writing and computer
a painful elbow lor a considerable length of time.
keyboard operation without significant exacerbation.
Becau s e he was m anag ing the business. he also felt
Being in a ma na gerial position. he felt he could not
fru strated that he was unable to take time off when he
reduce his work activity by taking sick leave. In add
first hurt his e lbow. He bel ieved that the pr oblem
ition. his soc i al life had been disr upted as he had been
would have settled if he had been allowed to rest
forc ed to stop playin g recreational bowls. Even t h oug h
initially and that he would not have been in the
the elbow problem was a sign iflcant intTusion in his life
present situation if his mecbanic had not been
.
Howard still felt able to cope and was n ot pa rticularly
tEl
off work.
PHYSICAL EXAMINATION
On physical examination. Howard had poor sit ting
more restricted tban flexion. Positioning the spine in
posture. with an in creased thoracic kyphosis. pro
combinations of extension with ri g ht side flexion and
tracted and depressed shoulder girdl e bilaterally and
right rotation. in addition to flexion with left side
an incr e a sed cervical spine lordosis. In the standing
flexion and left rotation. was p a in free although the
position. the upper limb s were held in inter n al rota
moveme n ts were l imited in range.
-
.
tion at the shoulder. both elbows were maintained in
Right and left s boulder mobilit y spec ifically abduc
slight flexion and both forearms were pronated. There
tion and hand behind b ack w as mildl y restricted by
.
.
soft tissu e
sti f fness. The addition of neu ral tissue-sensitizing
swelling or any other sign of de for mity in the elbow
manoeuvres sligbtly decreased the abduction and
was
no
region
evidence of
muscle
wasting.
hand-behind-back ra n ges of motion on bot h sides
.
equ al ly None of the se manoeuvres provoked the .
patient's symptoms. nor any disco mfo r t in the lateral
Active movements
elbow region. However. wrist extension in combin
Right elbow and wrist mobili ty was full and without
ation witb finger and full right elbow extension evoked
pain. C er v ical range of motion was limited in a l l direc
the patient s elbow pain with tbe right shou l d er in
tions by stiffness. Rotation and side flexion was more
either abduction or flexion. These same movements on the left side were completely painless.
restricted to the left than the right. and extens ion was
'
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
o
What was your interpretation of the postural observations? Specifically. what hypotheses did you consider and how did you plan to test these?
s tra ted abnormal postu ral features related to speciftc
pain sy nd romes such as cervical beadache (Haugbie et al.. 1995; Wat son and Trott. 1993). but other
• Clinicians' answer
investigations have found no such link (Refshauge
Abnormal posture is a frequent finding during rou
a com m o n form of spinal and upper limb postural
tine clinical examination. S o me studies have demon-
abnor m ali ty
et al.. 1995). This particular pati en t presented with
Copyrighted Material
.
It
has been prop osed
(Mack
and
CLINICAL REASONING IN ACTION: CASE ST UDI ES FROM EXPERT MANUAL THERAPISTS
Burfield, 1998) that forearm muscle imbalance and
extensors. In contrast. shoulder lIexion is usually less
abnormal radiohumeral alignment plays a significant
provocative than abduction to upper quarter neural
role in the prolongation of tennis elbow. Similarly,
tissue. Hence. there should be a greater pain response
White and Sahrmann (1994) contended that abnor
to wrist extension with the arm in abduclion rather
mal posture and related muscle function may lead to
than l1exion. if the upper quarter neural tissue is sen
repetitive microtrauma , which may be a factor in the
sitized. If the source of the symptoms is the extensor
development and maintenance of pain syndromes.
muscle origin (or structures other than neural tissue),
The therapist must, therefore, determine whether the
then wrist extension should be equally symptomatic in
patient's posture has any bearing on the development
shoulder abduction and shoulder nexion, as was found
or maintenance of the presenting condition.
in this case.
In this case, the postural assessment revealed no significant difference between the left and right upper limb , which may indicate that the variance in posture was not directly related to the pain disorder. However, the abnormal posture and possible related muscle dysfunction may have been a contributing factor to the problem. Lee (1986) has postulated that the type of head and neck posture seen in this patient may be a
precipitating factor in the development of chronic
tennis elbow. and that correction of this posture is an important aspect of treatment. The history of neck problems, abnormal bone scan findings in the lower cervical and thoracic spine. and the abnormal cervi cal and thoracic posture indicate the need to examine the cervical spine thoroughly. If the cervical spine was found to be a significant contributing factor to the problem. then the abnormal posture may need to be addressed. In addition, the flexed and pronated forearm posture may have been caused by muscle imbalance or joint restriction in the elbow complex, necessitating assessment of both muscle and articu lar function.
II
D
At this stage, were there any potential contributing factors (e.g. environmental. biomechanical) identified in either the subjective or physical examination that you considered may be relevant to the development or maintenance of his problem?
• Clinicians' answer Tennis elbow is not restricted to those that play tennis and other racquet sports (Kivi. 1982). It is common in the general non-sporting popUlation, especially amongst those whose occupations involve repetitive or forceful forearm, wrist and hand activities (Plancher et al.. 1996). particularly involving overuse of gripping and wrist extension. Following an extensive survey of 15000 residents of Stockholm. Allander (1974) reported an annual incidence rate for lateral epi condylitis of 0.1- H{, and a prevalence rate of 1-10'1'0. A number of factors can be identified from the subjective examination that may have contributed
What was your interpretation of the pain provoked by wrist extension and shoulder
to either the onset or the maintenance of Howard's lateral elbow pain: • a sedentary lifestyle. including working in an
movement?
office. that suddenly changed to a physically demanding job involving repetitive and forceful
• Clinicians' answer
wrist and arm activities. with the neck and arm in
Clinical experience suggests that peripheral nerve
awkward positions: although he had the skills
trunk sensitization frequently accompanies lateral
required to perform this job. he did not have the
elbow pain , with this finding also reported in the
necessary musculoskeletal conditioning
literature (Yaxley and Jul!, 1993). To determine the
• continuing to work as a mechanic for some time
presence of nerve trunk sensitization. an assessment
after the incident of loosening the corroded nut
for active movement dysfunction is needed (Hall and
would have amplified the problem
Elvey, 1999). The movements of wrist extension and
• activities (e.g. typing and writing) after returning
shoulder abduction are provocative to upper quarter
to normal duties may have delayed normal healing
neural tissue (Elvey, 1979; Kleinrensink et al.. 1995: Lewis et al .. 1998: Reid, 1987). Active wrist exten sion will also stress the origin of the wrist and finger
through repetitive overload stress • age
(51
years):
Putnam
and
Cohen
(1999)
reported slower healing times for older patients.
Copyrighted Material
6 A CHRONIC CASE OF MECHANIC'S ELBOW
sometimes be
Signifi can t factor in tennis elbow
In terms of the physical examination. the foll owing
can
factors may have contribu ted to the onset or mainte
(Gunn and Milbrandt. 1976: Lee. 1986).
a
nance of Howard's lateral elbow pain: • overactiv ity of the elbow t1exor and forearm prona
tor muscles may ind ica te abnormal funct i o ning of the upper limb muscles • active movement dysfunction of the cervical spine. Even t h o ugh the pati e n t demonstrated full range of
elbow and w rist motion. the resting posture suggests overactivity of the elbow t1exor and forearm pronator
muscles. This may be an in di cation of abnormal functioning of the upper limb muscles. A muscle imbalance may cause abnormal joint axes of rotation
and repetitive microtrauma from ever yday joint movement (White and Sahrm ann 1994). Mack and .
Burfield
(1998)
have
proposed
that
imbalance
between th e forearm supinator and pronator muscles
is a causative factor in tennis elbow. PhYSical examination of the cervical spine revealed evidence of active move ment dy sfunct ion altho ugh .
not
symptomatic.
Bone
scan
imaging
showed
increased tracer u ptake in the C5-C6 facet jOints bilat erally. Some authors have pro posed that clinical and subclinical neuropathic disorders of the cervical spine
• Clinical
reasoning commentary
Although observation is just one small part of the physical examination in this ca se it is interesting to .
note how the ilndings from this common 'test' can be used to form and test hypotheses in severa] cate gories. Tbe I1 n dings have informed decision making related to the physical impairments (e.g. j O i n t restriction in the elbow) and sources of the elbow pain (e.g. cervical spine). factors contributing to t.he pr o blem (e.g. abnormal posture). and ma nagem en t and treatment (e.g. postural correction). as well as directing later search strategies. such as the need to examine the cervical spine. Tbis illustrates the abil i ty of the expert to recognize the relevance anel meaning of clinical features. and the asso ciated implications [or subsequ en t actions. In addition to improving the accuracy of decision making. this also enhances the effkiency of the overall clinica l reasoning proce ss Extensive clinical experience, and relle c tion about such experience. is integral to developing this ability .
.
Muscle tests
Passive movements
Signillcant pain was reproduced on palp at ing the ori
Mild p ain was reproduced and abnormal s ti ffness
gin of the right extensor carpi radialis brevis muscle
detected on passive accessory motion testing of t h e
on the anteroinferior aspect of the lateral epicondyle.
right radiohumeral jOint but not the humeroulnar
as well as th e proximal muscle mass of the w rist and
jOint. nor tbe joints of the left elbow complex Pain
finger extensors. Gripping with mi l d pressure repro
and stiffness was more apparent with the right elbow
duced the pain with the elbow flexed or extended. but
in full extension and pronation. Neural tis s u e provo
.
only in forearm pronation. Isometric contraction of
cation tests biased to the radia l and median nerve
the wrist and finger extensors also reproduced t h e
tr unks did not reproduce the sy mptoms
elbow pain. Isolated isometric contraction of the mid
range of movement was equal between sides. Normal
dle finger extensors was notably more painful. but
responses were elicited on p al p ation of the nerve
,
and the
testing of the lorearm supinators was symptom free.
trunks in th e upper limb. Passive physiological motion
Stretching the wrist into flexion was provocative. par
testing of the cervical and thoracic spine revealed
ticularly with the forearm pronat ed and the elbow
marked restriction of movement at CS-C6. C6-C7
fully extended. Muscle l ength of the forearm supin
and from T3 to T6. Passive accessory motion testing
ators and pronators was assessed indirectly by observing
indicated a pain and stiffness relationship at the same
the range of active m ove ment of forearm pronation
spinal levels. It was no t possible to r eproduce the
and supination and found to be normal. Further
arm sy mptoms using any provocative manoeuvres of
assessmen t for muscle imbalance was left for a later
the cervical spine.
session (if necessary) because the principal goal of the initial assessment was pain relier.
The
effect
Copyrighted Material
mobilizations
of
(MWMs) (Mulligan
.
with
movement
1999) of the elbow was also
C L I N I C A L REAS O N I N G I N ACT I O N : C AS E STU D I ES F RO M E X P E RT M A N UAL T H E R A P I STS
assessed . Th is was co ns i de red wor thwh i l e as t hey often have the elTect of i n c re a s i n g fu nction wh i l e a t the s a me t i m e red u c ing p(] i n . an d do not us u a l ly req u i re a r e duc t i on i n du ties at h o me or work . MWMs are sustained mob i l i z a tions ( accesso ry gl id es ) of a j oi n t Si mu l tan eo us ly
a pplied
with
the partic u l a r
move ment t h a t i s pa in fu l or res tricted i n r a n g e . [ n c a se s o f so ft t i s s u e l e s i o n s ( s u c h as te n n i s e l b ow ) . the gl ide i s acco m pa n i ed by contra ct i o n o f the muscles s u r ro u nd i ng the
j o i n t . The m o s t i mp o r t a n t p ri n ci p l e
to fo llow i n us i n g MWMs is that the p a i n associated with
the m u scl e c o n traction o r j o i n t move ment
should be co mpletel y relieved by t h e mob i l izatio n . In some i n s t a nc e s . pai n may not be relieved at the
F i g. 6 . 2
Late ral g l i d e of t h e e l b ow.
fi rs t attempt a n d the t hera p i s t must adj u s t eith e r t h e force of t h e gl i d e or t h e p l ane in w h i ch i t i s made. F u r t h e rmore . the gl ide should be a p pl i e d as close as
border of the h u m er us . as c lose as poss i b l e to the
po ssi ble to the j o i n t l i ne . If p a i n i s no t a l l e v i ated. even
el b ow j o i n t l ine ( F i g .
after adj ustments are made by the thera p is t . then
the
6 . 2 ) . T he other h a n d was pl ac ed
j ust d is tal to the j oi nt l i ne on the med i a l border of t h e
tec h n iq u e i s not i n d icated and shou ld not be used . In
u l n a a n d mobi l iz ed i n a late ra l d irec t i o n . The gl ide
c a ses o f c h ronic ten n i s elbow. the passive a ccess ory
was sustai ned w h i le the pa tie n t p er lo rmed
moveme n t that u su a l ly r e l ieves p a i n is
that n o rma l l y reprod u ce d h i s symptoms ma r ked ly.
a
la tera l g l id e
an
a c t i vity
of the u l n a a nd rad i u s on the h u m e r u s (Mu l l i ga n .
G r i p p i n g was chosen as i t was I'u nctio n a l
1 999).
be e a s y for t h e p a tient t o perk) [ [n a t h o m e a t
To deter m i n e whe ther the t e ch n i q ue was i ndicated a l atera l gJ i de was
tria led . The prox i m a l aspect of the
e l bow w a s s t a b i l ized w i t h one h and over the la tera l
wo u l d
and
a
l a ter
s t age i f necessa ry. It was lo u n d t h a t t h e pain n o rm al l y
ca used by gripping was not prese n t d u r i n g t h e
appli
ca tio n of th e l atera l g l i d e .
R E AS O N I N G D I S C U S S I O N A N D C L I N I C A L REASO N I N G C O M M E N TA RY
D
What was yo u r wo rking hypoth e s i s at the c o n c l u s i o n of t h e phys i c a l exa m i nati o n ? What c l i n i c a l fi n d i ngs te n d e d to s u p p o r t or d i s c o u n t yo u r th i n k i ng!
F i n d ings in sup po r t of l o c a l s tr u c t u re s a s
a so urce
of pai n i ncl u d e : • s y mp tom reproduction
on
a c t i ve wrist extension
was u nc h a nged with e i t h e r
shoulder flex ion or
e lbow Ilex i o n
• C l i n icians' an swe r
• symptom re prod uc t i on o n m i l d ly fo rceful g r i p p i n g
The p hysic a l exa m i n ation fi nd i n gs correlated we l l
• sym p tom reprod ucti o n o n isometric contraction o f
with t h e s u bj ecti ve com p la i n t a nd s ugges t ed a dis order cha racteri s t ic of l atera l epicondy l i t i s . There was
the wrist and fi n ge r exten so r s . a n d i n pa r ti c u l a r t h e m i d d le fi nger ex ten so rs . wh ich a r e t h ou g h t to
s tron g evid ence of l oc a l structures as th e source of
i nd i c a t e involveme n t of e x tensor carpi rad i a l is
the sym ptoms . n amely extensor c a rpi r a d i a l i s brevis a nd the rad i o h u mera l j O int. There was l esser ev i de nce for refer re d p a i n
(rom remote sources . [t was pro b a b le
brevis ( Wad swo r t h . • pain on s tretc h i n g
1 9 8 7) the f mger extensors
• symp tom reprod uctio n on pa l pat i on of the l a teral
t h a t t he cerv i c a l and t h o racic s i g n s were related to a
epicond yle at the s i te o f th e origin of the extensor
c o i n cide n t a l degen e ra tive disorder a nd the re was no
c a r p i radi a l is bre v i s m uscle ( Noteboom et a l . .
ev ide nce o f n e u r a l tissue i nvolveme n t .
• n o p a i n o n g rippi ng wit h the M W M .
Copyrighted Material
1 9 94)
6 A C H RO N I C CASE O F M E C H AN I C ' S ELBOW
1;1
sy mptoms . by way of axonal compro
S o me w h a t i ncon sistent wit h t h is hy pothesis ( b u t n o t
of
u n commo n ) w a s the fi nd i ng o f p a i n o n gri p p i n g w i t h
mise or dysaesthesia , t hen app lying
t h e e l bow ei t h e r l'lexed o r ex tended . The find i n g o f
movements to c l ose the ri ght lower cer v ical i n ter v er te
rad iohu me r a l j oi n t dysfu n ction o n p as s i v e accessory m o tio n tes t i n g was a lso i nconsistent with a tend i n o
rig h t rotati o n ) should be provoc a tive . Aga i n . t h i s was
Find ings i n s uppor t o f remote s tr uc t u res a s a
movement dysfunc c l i n i c a l pattern consistent
• c e r v i c a l a c t ive a n d c o m b i n e d
• bone
Brm
sca n
a
symptoms
a b n o r m a l i t y a t C S -C fl ,
c o n s i s t e n t w i t h the
arm
a
c erv ic a l l e vel
symptoms
• c e r v ic a l p a s s i ve phys i o l og ic a l move m e n t d y s fu n c t i o n in a reg i o n the
arm
a
com b i na ti o n or
fora men ( exten sion w ith r i gh t s i d e l1ex ion a n d
was consistent wi th ne u ra l tissue sen s i tizatio n (le ft side f1ex i o n ) , b u t fur t h er testi ng n egated th i s poss i b i l i t y,
sou rce of p a i n i n c l u d e :
with th e
b r al
arm
not th e ca se. Cervic a l active movement limitation
p a t hy as the so u r ce o f pai n .
t i o n , a l t h o u g b not i n
the
(C )-C fl , Cfl-C 7 ) c o n s istent w i th
s y m p toms
• the pain and s ti ffness relati o n s h i p fou n d o n pa s s ive ac cessory motion testi ng in
a
re g io n
(C5-C 6 ,
Tend i ng to negate the cervi c al spine as a source of the pa i n was the i n a b i lity to re prod u ce a ny a nn symp toms using a range of p rovoc a t ive manoeuvre s . There was a lso no evidence of a neurogen ic disorder. N e u r a l
tissue provocation tests. outlined by H a l l and Elvey ( 1 9 9 9 ) , fa i l e d to re vea l a ny S i g n i fi c a n t a b n orma l i t y. A neurological examination was n o t
u nder t ake n as i t
is u nlike ly t o b e sul"ficien tly se n siti ve t o detect the m i ld signs of neural co mprom ise that m ay be presen t i n ten nis elbow ( G un n and Milbrand t. 1 9 7 6 :
Lee. 1 9 8 6 ) .
C6-e 7 ) co ns is te n t w i t h the a r m sy m p to m s . Assessmen t of cer vi c a l act ive movements r e ve a l ed
• C l i n i cal
reasoni ng commentary
l imi tation of movement witho u t p a i n . C l i n ical p a ttern
Th i nki n g rela ted to the recogni tion of c l i n i ca l
recog n i t i o n fo r arm p a i n , be i t a mechan ica l n ocice p
patte r n s i s evident in this response. Pattern recog
tive or neuropathic d i sor de r. is dependen t in p a r t on
nition,
k ey act ive and c o m b i ned movemen t
combin ations, Clin ical pa ttern s can be recogn iz e d fo r ce r v i c a l neural
matically used by expe r t cl inicians , is an emc ient
tissue sensitization, ce r v ic a l neu r a l ti ssue axo n a l
c l in ical data and making appropriate clin ical deci
and
a
h a l lm a rk o f t he clinical reaso n i n g auto
a cc u r
a te process for handling large amounts of
com prom i se/dys aesthesia , a nd cer v ic a l somatic tissue
sions. Nevertheless, these patter n s must still be
dysfunction ( d isc a nd facet j oi n t) . Com b ina tio ns of the
tested to determine whether they are correct i n
most restr i cted active movements did not provide
p ar ti cu l a r cl inic al case,
evid en c e o r
a regul ar stre tch or comp ressive p attern
as o u tl i ned by Ed wa rd s ( 1 9 9 2 ) a n d O l iver ( 1 9 8 9 ) ,
a
In t his case. clinical patterns were sought, but were u n able to be verified. for cer v ica l neural ti ssue sensitization. cervical neural tis
U rig ht - sid e d cervical somatic structures were t h e
sue
source o f t h e e l b ow sy m ptoms , t h en a pplying i ncre as
so ma tic tissue i mp airme n t (disc and fa cet j o i nt ) .
i ng stress in a reg u l a r, prog ressive fashion either to stre tc h or to c om press those tiss ues would h ave g iven a
and combined movements. in addition to later neural mobil ity testin g . en abled
p red ic tab l e pain provocative response. This was n o t
the reranking. if not almost rej ect ion. of these
the c a s e , If cervi c a l neural structu res were the source
bypotheses i n
axona l compromise/dysaesthesi a . and cen7ical
Testin g by way of active
p ain at a l l .
an
efficient and logical
m a nner.
If pain is provoked, then the patient m u s t
i n form the thera p is t i mme di ate ly to prevent ex a cer
• Treatment
ba ti ng the cond itio n , In ad d itio n , the patient i s g iven
1
to u n d ers ta n d that a pos i ti o n a l faul t o f the bones
T h e tre a tme n t c h o sen consisted of an MWM to the
i n th e elbow joint c a n cause ab n orma l p u ll i n g of
elbow usi ng a later a l glide with g ri pp i n g , A thorou g h
the ex tensor muscles a t the elbow and be a co n tr i bu t
explan a tio n
i n g fac tor to c h ro n i c ten n i s elb ow, If th is is
was
give n to the patient about the
the case.
pri nciples beh i n d the t ech n iq u e before mobil ization
t he n correction of the pos itio n a l fa ult by l atera l gli d
was co mmenc ed , It is impor t a n t t h at the pati e n t
ing o f t h e bones s h o u l d a l low g rippi n g t o become
u n ders t a n d s th a t t h e tec h n iqu e s h o u l d c a u s e no
pa i n - fre e .
Copyrighted Material
CLINICAL REASONIN G I N ACT ION : CASE STU DIES F ROM EX P E RT MAN UAL T H E RAPI STS
Fig. 6.4
Fig. 6.3
M o b i l i zation with move m e n t fo r te n n i s
Ta p i n g te ch n i q u e fo r te n n i s el bow.
with o u t p a i n . The strap p i n g tape had i r r i tated his
e l bow u s i n g a trea t m e n t b e l t.
skin and was removed the mor n i n g a fter the first . treatment. T he s k i n where the tape had been app l i ed
A ma n u a l therapy belt was used to m a i n t a in com
was s l ightly red. No fu r t her strapping tape was used .
for tably s u fficient latera l g lid e force to relieve pain
On reassessment. gripping was comfortable u nt i l a
completely while the agg ravating ac tivity o f gripp i n g
modera te force was a p p l ied. whereupon pain was pro
was u ndertake n ten t i mes i n s uccessi o n (Fig. 6 . 3 ) .
vo ked wi th the elbow in eithe r fu l l extension
or
90
A t the end o f ten repetitions. reassessme n t demon
d eg r ees Oex i o n . Pai n o n resi s te d isometric wrist and
strated that mild gripp i n g was pain-free. Modera tely
fin ger exten s i o n . a nd local tenderness i n the reg i o n of
forcefu l g ripping and resisted finger ex te n s i o n were
the attachment o f extensor carpi rad i a l i s brev i s . was
still p a i n fu l . The s a me technique was repeated [or two
unch a n ged fro m the prev ious ex a mi n a t i o n . Pain was
more sets of ten repe titions. S ubseq u e n tly g ripp i n g
a lso elici ted on active wrist exte n s i o n with the elbow
w a s complete ly p a i n - free.
in fu l l ex tension and pronatio n a n d with the a rm
Strapping tape was appl ied to the elbow in s u c h a fas h ion as to replicate the l a teral g lid e . in an attempt to m a i n ta i n the e ffect of the tech n ique (F ig. 6 . 4 ) . The
positioned several "v ays . i n c l u d i n g by the s i de. in 9 0 d e g rees Oexion a n d i n 9 0 deg rees abductio n . Because o f the su ccess o f the i n i t ial trea tment. a
p a t i e n t was ad vised to wea r the tape for 4 8 ho urs i n
d ec i s i o n was made to i ncorporate
order t o m a i n t a i n the effect of t h e treatment. The
programme i nvolv i n g the l a tera l gJ ide tec h n ique.
need to remove the tape in the eve n t of skin irri ta tion
Howard was shown a s i m p l e mea ns o f repl icating the
wa s stressed because of t h e h istory of dermati t i s . T o determ ine t h e effic acy of the t h era py. Howard was i n s tructed to carry out his n o r m a l home and wo rk activ i t i e s , and asked to return in 2 d ay s .
a
s e l f- m a n agement
tec h n ique u t il izing a broad belt a ro u n d the circumfer ence of the body l a teral to the h u merus and j u s t prox i m a l to the elbow j o in t l i ne ( E-'ig. 6 . 5 ) . The patient appl ied the latera l g l i d e w i t h his l e ft h a n d . He was instructed that at no t i me s h o u l d the
• Treat m e n t
tec hnique be p ai n fu l. If p a i n occur red . t h e n the tech
2
n ique was e i ther to b e a dj usted u n t i l it became p a i n
On retu r n i n g . the p a t i e n t reported s i g nifica n t reli e f of
free or aba ndoned. Howard w a s asked to demonstrate
symptoms after tre a t me n t . w i t h less-freq u e n t pain
the techn iq u e and g u id ance was given o n the appro
and the abil ity to ty pe a n d write fo r longer pe r i od s
priate method . Using this appro a c h . Howard was able
Copyrighted Material
6 A C H RO N I C CASE O F M EC H A N I C 'S E L B OW
h owever n o t to the s a me deg ree as
at the in i t i a l exam
inalio n . T h e movement of ac tive wrist exte n s i o n with the e l bow in fu l l ex tens i o n and p r o n a tion a nd with the a rm by the side. i n 9 0 deg rees l1ex i o n and in 90 d e g rees abduction, was only m i l d ly painfu l . S tretch i n g t h e extensor m u s c l e s usi ng fu ll wrist l1ex i o n w i t h a n exten ded / p ro n a ted elbow w a s n o l o n ge r pa i n fu l . In additi o n , the deg ree of sensitiv i ty o n p a l pa t i o n of the common
ex tensor
origin
and
muscle
mass
was
ma rkedly reduced . A decision was made to m a i n t a i n the l a teral g l i de but
ch a n ge the active component to resisted i s o metric
wrist a n d fi nger ex te n s i o n . ra ther than gripping. The p a i n - free isometric contrac t i o n was s us t a i ned for 3 seco n d s a n d repeated 1 0 t i mes i n su ccess ion . Four fu r ther sets were incl u ded in t h i s treatment sess i o n . The only mod i fic a t i o n to t he home
exercise was a d d i n g
end-ra nge w r i s t exte n sion to clenc h i n g o f the h a n d . Fig. 6.S
A t t h e e n d o f t h e treatment sess i o n , Howard h ad
Se lf-treatment fo r ten n i s e l bow.
p a i n-free resisted isome tric fm ger a nd wrist exte n s i o n , as well a s fu l l p a i n-free g r ip strength. It was th ought
to e l i min a te all p a i n w i th moderate gri p p i n g force. He
that a tri a l game o f lawn bowls wo u l d be appropr i a te
was advi sed to perform 10 repe t i t i o n s of the exercise
to d e te rmi ne the degree of improvement. An appoi nt
three ti mes per day.
m e n t was arra n ged for 1 week to review prog ress .
Thera pist i n terven t i o n consi sted of a sustained lat eral gl ide u s i n g a belt. wh i le
the patient performed 10
repe titions of grip p i n g . Three sets were u nd er taken
• Treatme n t 4
with the elbow in fu l l extension and a fu rther three
Howard repor ted that s ince the previous treatme nt ses
with the elbow in 90 deg rees flexion. On reassessment.
s ion there had been no d iscomfort with everyday work
gripping was no longer p a i n ful in exten sion or l1exion;
and home duties. He had played a fu l l game of bowls
however res i s ted isometric wrist a nd fi n ger extension
and carried the ball in his ri g h t hand without
continued to be symptomatic. Ac tive wri s t exten s ion
There had been a llare up of symp toms after working
w i th the e lbow in fu l l extension a n d pronation and
for 3 hours on his son's
w ith the arm by the side, in 9 0 degrees llexion and in
socket driver appeared to be the aggravating activi ties .
9 0 d egrees abduc tion, wa s less p a i n ful than at i n i ti a l
This exacerbation settled a fter performing his home
eval uatio n . Howard w a s adv ised t o c o n ti nue h i s nor
exercise the next day.
mal d a i ly activi ties and to retur n i n 4 days.
d imculty.
car. Using a screwdriver and a
On p hysical exa m in a t i o n . the o n ly activ i ty t h a t reprod uced p a i n was resi sted i s o m e t r i c m i d d l e fi nger
• Treatment
e x tens i o n . There was m il d tender ness o n p a l p a t i o n of
3
the atta chment of exte nsor c ar p i rad i a l is b rev is a n d
Howard repor ted no d isco m fo r t w i th w riti n g b u t still
t h e assoc i a ted extensor m u scle m a s s . T h e movement
complained of p a i n with compu ter key board a n d
of active wrist exte n s io n w i t h the elbow
mouse activ i t i e s . S having a n d teeth c l e a n i n g h a d not
s i o n and pro n a tion, w i th the a rm by the side, i n 90
been pro b l e m s . He had noticed c a r ry i ng a heavy b a g
degrees flex ion and in 9 0 degrees abducti o n , was not
i n h i s r i g h t h a n d h a d aggravated h i s symptoms for 1
p a i n fu l . Wri st and fi n ger extensor muscle s tretc h was
in fu l l exten
accessory motion of thera d io
d ay. Regu l ar use of the presc ribed exerc ise m arkedly
now pa in-free. Passive
relieved the symptoms the next d ay.
h u meral j O i n t was still restricte d by s t i ffn ess, bu t p a i n
O n p hysic a l ex a m i n a t i o n , gri p pi n g was p a i n-free
w a s no l o n g e r evoked .
i n fu ll exte n s i o n and 90 d e g rees l1ex i o n . b u t resisted
Therapist i n tervention was the s ame as that pro
was s t i l l p a i n fu l .
vided a t the previous sessi o n . Five sets of 10 repetitions
isometric wrist and fi nger exte n s i o n
Copyrighted Material
CLI N I CAL R EASO N I N G IN ACTION : CAS E STU D I ES F ROM E X P E RT MANUAL TH E RAPISTS
o f r e si s ted isometric wrist and fi nge r exte n s i o n , with each con traction held fo r 3 se conds, complete ly abolished the pain w i th all mus cl e contraction tests. Howard was advised to carry o n with the self� m o b il iz a ti o n tec h n i ques on a d a i ly b a s i s for the nex t week , or lo n g e r i f t h e el bow continued t o b e a pr o b le m . In an attempt t o prevent future rec urrences , a ten n is e l bow brace ( e pi co n dy l i ti s cl asp) was provid ed for u n a c c us t o m e d a c ti v i t i es i nvo lv i n g forcefu l gripping. The b r a c e w a s rec o m mended to r e d u c e t h e stress on the c o mmon extensor origin from fo rcefu l gripping acti vities . It was t ho u g h t that u n accustomed fo rcefu l use of the wr i s t a n d fi n ge r extensor a nd fore arm pronator muscles could overload the common exte n s o r o r i g i n a n d provoke a n e w episode of pa i n . The mechanical role or the brace w a s to spread the forc e
of gripp i n g over the whole fo r e a r m and so re d uce the overall load at the co m mo n ex te n s o r or i g i n It h as been s h own that simi lar c l asp s can sign i fican tly i mprove pa i n - free grip strength in su ffe rers of ten nis elbow (Burton, 1 9 8 5 ) . A s t hi s e piso d e had been ca used by overs tress o f the fo rearm musculature, Howard was also p re s c r i b e d exercises for improving co ntrol of the forearm s u p i n ator a nd pro n a to r muscles , as we l l as t h e wrist a n d fi n ge r ex tensor and f1exor muscles. It was ex p l a i n ed to the p a ti e n t th a t this was to prepare the el bow joint and f'orearm mu scles for fu ture forceful gri pp i ng activities. Howard was a l so advised to resume the seJf mobi l ization e xer c i ses in the e v e n t of recu rrence and to con t i n u e w i t h th e m [or 1 week a fter the symptoms su bside . .
REASO N I N G D I SC U SS I O N A N D C L I N I CAL REASO N I N G C O M M E N TA RY
D
What caused to you to sel ect t h e chos e n MWI"1
this case, as the p a ti en t had been referred fo r st re n g th
as you r treatment?
ening an d s tret c h in g exercises by h i s r h e u m a t o l o gi s t .
• C l i ni c i ans'
o
an swer
Historica lly, te n n is elbow has been a di ffi cu l t p ro bl em to treat. with a wide variety of procedures and m a n age m e n t pro toco l s advocated (Cald well and Safran, 1 9 9 5 ; Noteboom et a l . , 1 9 9 4 ; Putnam and Cohen , 1 9 9 9 ; Reid and Ku s hn e r, 1 9 9 3 ) . G e n e ra l l y, treatment is pro l o n ge d and lo n g ter m o u tco m e s questio nable (Mack a nd B u rfield , 1 9 9 8 ) . When ind icated , th e MWM for tennis e lbow described by Mulligan ( 1 9 9 9 ) is a si mp le but extremely effective means o f trea ting th i s d iso rder. However, an indication for use is only determined by trial a pp l i ca ti o n o f t he te ch niqu e . Therefore, the reasons for selection of an elbow MWM fo r t re a t men t were :
Could you elaborate fu rth e r regard ing the pathobiological mechan ism fo r t h i s case of te n n i s e l bow? What did you co nsi d e r cau sed the positional fa u lt i n t h e first place and what s u bseq u e ntly mai ntained it?
• C l i n i c ians'
answer
-
• i mm ed i a te abolishment of pain d uri n g the tr i a l • pr evio us experience and kn owl edge of efficacy of
the te c h n iq ue • po ten t i a l for integration into a h ome treatment
p ro g r a m m e suitable fo r the patient's prese n ta t i o n
It is p ro b a b le that the p a t ien t developed lateral elbow pain as a r es u lt of un accustomed use ( as wel l as over use) of the forearm pronator and the wrist and finger exte nsor muscles d u r i ng the 2 -week period he worked a s a mec h a n ic. His a ttempt at free i ng the corroded n u t also re qu ir ed sustained , excessive grippi n g , fo r ear m pron a t i o n and wrist extens i o n force . The pa ti e n t , therefore, su ffered a sudden stra in , as well as r ep et i t i ve m icrotrauma, to the musculotendinous i nsertion, thus ca u s i n g tissue damage. The consequent scar ring, possibly conSisting of granulofi broblastic m aterial s among others, subsequently became infi ltrated with free nerve e nd i ngs It is known t h at gra nu l o fib rob l a s tic materi a l laid down i n the repa i r process of te nnis elbow contains free nerve en d i ngs ( G o l d i e , 1 9 6 4 ) . I t w a s fo u n d t h a t r ep os i ti on i n g t h e u l n a and radius wi.t h respect to t h e h u merus completely abol ished t he patient's pa i n . It w as hy pothesized th a t .
a nd lifestyle. F u r thermore, the i mmed iate a n d marked re d u c tio n in
symptoms w i th the tech n i q ue was helpfu l i n ga i n i n g the patie n t ' s co n fi d en c e a n d co m p l i a nc e in his reha bilitation process . Th i s wa s p ar ti c ul a rly i mportant in
Copyrighted Material
'
'
6 A C H RO N I C C A S E OF M EC H A N I C'S ELBOW
ma l positi oning of the u l n a and radius was caused by
gl ide is di rected is d ependent o n the orientation o f the
the excessive forearm pron ation and wrist extension
concave joint su rface. often referred to as the treat
force used to loosen the cor roded nut. This excessive
ment plane (Kaltenborn. 1 9 8 0 ) . F a i l u re by the thera
force was not matched by adequ ate con trol of the
pist to apply the gl ide parallel to this treatment plane
a ntagon ist fo rearm muscles. particu larly the supina
will result in compression of t h e j o i n t surfaces and
tor. T h i s i n formation . together wi t h the other fin d ings
consequently ca use pain (Mulligan, 1 9 9 9 ) . In many
from the c l i n i c a l ex a m i n a tio n . i n d icates that th is
cases. the therapist may not apply the glide precisely
patie n t ' s pain prob lem was a mech anica l nocicep tive
i n the right directi o n i n i t i a lly. If the thera pist is
disord er invo l v i n g the elbow j o i n t complex, as we ll as
unable to relieve the symptoms w i t h the glide, then
that a ri se from the common extensor ori the l a teral e p i c o n d y l e . A b n o r m a l posi tioning o f
subtle c h a n ges in t h e glide a n gle should be e mployed
t he musc l es g i n at
the u l n a a n d r a d i u s d u r i n g activities that involved
to abolish symptoms completely d u r i n g the accom pany i n g movemen t or muscle contracti o n .
con traction of the fi n ger a nd wrist exte nsor muscles,
Faulty j o i n t alignment c a n mechanicaJ ly distort
parti c u l a rly w i t h the forearm i n pro nation ( typing.
scar tissue and thus stimulate the i n situ free nerve end
wri ting. teeth clea n i n g , sh aving . etc . ) . S i g n i fi c a n tly
ings laid d own in the repa ir process sufficiently to evoke
loaded the attachment of the extensor muscles and
mechanical nociceptive pain. Correction of the j oint
caused p a i n . Repeated overuse of the fo re arm prona
mala l ignment by MWM may reduce the mechanica l
tor and wrist and fi n ger extensor muscles during
distor tion of the scar ti ssue and so relieve p a i n .
these activities m a i n t a i n ed the bony pos i t i o n a l fa u l t at the el bow. Repea ted abnormal l o a d i n g o f the
C o n s i d e r i ng the p roposed p o s i t i o n a l fau l t
rep airing musc u l o tendinous i n sertion maintained
mechan i s m . w h a t w a s yo u r i n te r p retati o n
sensitiza tion (cen tra lly a nd /o r peripherally) o f the
o f the phys i c a l signs t h a t suggested
nociceptors and ot her receptors in the scar tissue,
a m u s c u l ote n d i n o u s path o l ogy rath e r than
conseq uently m a i n ta i n i n g the pain disord er.
a joint path o l ogy ?
The concept of abnormal bone positi o n i n g has been proposed by Mu l ligan ( 1 9 9 9 ) as an exp l an ation fo r the purported success o f MWMs in the treatment o f
• C lini cians' an swer
chronic tenn is elbow a n d other disorders . Mack and
It is impor t a n t to u nderstand t h a t the hy pothesis o f
Burfield ( 1 9 9 8 ) Similarly hypothesized that l ack of
malpos i t i o n i n g o f the u l n a and rad i u s i n re lation
ecc entric con trol of fo rearm pronation leads to exces
to the h u merus does not preclude
sive media l and inferior displacement o f the head of
the muscul otend inous insertion. The phYSical signs
the radiu s . which s u bsequently increases the load on
fou n d a re consistent with a musculotend i n o u s patho
a
problem with
the common extensor origin at the l ateral epicondyle.
logy. as well as a n elbow j o i n t complex pathol ogy.
Eccen tric control of forearm pronation. and therefore
Malposition i n g of the u l n a and rad i u s in relation to
lateral elbow stabil i ty, is p rovided by the supinator
the humerus creates an increased load on the muscu
muscle ( S troya n and Wilko 1 9 9 3 ) with i ts close attach
lotendinous attachme n t during gripp i n g a n d wri st
ment to the lateral epicondy le, radia l collateral a n d
and fi n ger extension task s . Nociception arises [rom
annular l igaments (Mack and Burfield , 1 9 9 8 ) . The
mechanically evoked responses fro m receptors in
concept of abnormal humerou lnar and radiohumeral
the repairing scar tissue at the muscul otendinous
ali gnment in tennis elbow is supported by the results
attachmen t . rather t h a n from j u s t the j oi n t complex
of a single case study design by Vicenzino and Wright
itself. RepOSition i n g the u l n a and rad i u s in relation
( 1 9 9 5 ) . They demonstrated th at the lateral glide
to the humerus normalizes loadin g o n the attachment
MWM of the elbow (Mulligan. 1 9 9 9 ) , which might
during gripping and other tasks , thereby reduci n g
potentially correct the med ial rad i a l displaceme n t
mec h a n i c a l provocation o f t h e sensitized receptors
described b y M a c k a n d B u r fi e l d ( 1 9 9 8 ) . imme diately
within the scar tissue.
relieved the pain experienced during gripping tasks and normal fu nction was rapidly restored.
The fi nd i n g of increased stiffness to passive acces sory motion testing o f the radiohumeral j o i n t was not
However, c l i n i c a l experience indicates that close
en tirely consistent w i th a j o i n t i n s t ab i l i ty problem.
atte n ti o n to technique with respect to the a n gle and
With a n in stability probl e m . one would a n tiCipate
pl ane of the gl ide is criti c a l to the s uccess o f MWM. In
hyperm o b i l ity rather tha n hy pomo b i l i ty, unless there
a concave/convex jOint. the plane i n wh ich the MWM
was associated muscle guarding.
Copyrighted Material
C L I N I C A L R EAS O N I N G I N ACT I O N : CASE STU D I E S F R O M E X P E RT M A N UA L T H E RA P I STS
H ow d i d you ga i n the pati e n t's consent fo r the
fmger extension was d imini s h e d to some deg ree . The
MWM i n terventi o n w h e n h e had b e e n refe rred
reason for this may be that the force requ ired to repos i tion the radius with res p ec t to the humerus fo r pain
fo r strengthe n i ng and s tretc h i ng exercises ?
free gripping wa s
• C l i n i c ians'
answer
less them that required for
pain-free
isome tric wrist and fmger extension. This could b e
The MWM is an i n te g r a l part o f the asses smen t
process. The p a tien t was informed that in the op i n io n of th e ex aminer there was a p osi ti on a l fa u l t of the bone s that make up the elbow j oint. The relief o f p a in on M W M tes t i n g while gripping ver i fi ed th i s fi n d i n g
because gripping is a less-stressfu l activ ity for the mus cu lotendinous attachment at the lateral epicondy le Conseq uently it wa s p l a n ned to
co m
w i t h isometric ,"vrist and fm ger extension as
sion of treat m e n t
.
b ine the MWM pr og res
a
.
.
The patient could see that restoring the a l i g n ment o f the bones h a d a llowed norm a l p a i n fr ee functi o n -
i n g o f the w r i s t a n d fo re ar m muscles . It w a s a l s o
exp la i ned that i f the techn i q u e was repea ted a num
t h i s would permit t he mu scles to be exe rc ised p a i n l e s s ly and wou l d h a s te n the recovery ber of times
process As well . it wo u l d a l low th e p a t i en t t o p er fo r m .
h i s no r m a l d a ily d uties . Therefore,
inconsistent w i t h
MWM is not
th e d o ctor ' s req u e s t for stre n g then
i n g e xerc i se. Grad u a ted mu scle a c t iv i t y is a n integral
par t of the treatment p ro ced ure The passive mo bi .
l ization component of
the MWM a l lo w s the exerc ise
to be p er for med w i thout pain.
• C l i n ical
reaso n i n g com m e ntary
The s e l e c t i on of MWM for the t re a t men t sheds light o n some i n te r es t i n g aspects of e x p e r t cl i n i c a l rea s o n i n g . T h is m a n ag e m e n t decision
was
based
on seve r a l re a s o n s rel a t i n g t o the past. the prese nt
and the fu ture. F i r s t . past
e xper i e nc e
with s i m i l a r
c l i n i ca l p rese n t a t i o ns . a l o n g w i t h k n o w l edge o f
prel i minary
researc h
evidence.
has
greatly
i nfo rm e d t h e treatment decisi o n . Recog n i t ion of
t h i s partic u l a r clinical pattern i s Clssoc i a ted with
specific actions. i n c l u d i n g i n terve n t i o n s . t h a t h ave
We re you expecting t h e M W M s i nvolving gri p p i n g to have a greater effect upon res isted wrist and fi nger exte n s i o n ? Why d i d yo u th i n k that the effect was l i m i ted ?
previously been fo u nd to be productive. Second ly. the present finding of immediate a bo l i ti o n of pain with the application of MWM is
a
defi n i n g resu l t
from t h e ' tria l treatm e n t ' test . T h e hypo thesis o f
l o c a l elbow musculotendin ous a nd j o i n t patho l o gy receives stro n g support from this find i n g , but of
• C l i n i cians' an swe r
greater i mp o r t a n c e is the su pport it p r o v i de s fo r
Isometric wrist and Hnger exte n s ion is usu ally more
t he application of MWM for treatment purposes.
to the muscu lotendinous unit at the lateral
as su gge s t e d by past experience. Fina l ly. it i s a n tic
e pi co n dyle tha n gripping. Clin ically. g r i ppin g is some
ipated that i n fu tu re manageme n t the use of
times only mil dly evoca tive of lateral elbow symptoms .
MWM self-treatmen t will be valuable. perhaps to
provoc ative
wherea s isometric wrist a n d fmger extension is more
a cce l e rat e recovery and enable patients to become
fre qu e n t ly in te n se ly evoca tive. However, with Howard .
more actively i nv olv e d a n d respon s i b l e for their
grippi n g was incorpora ted in to the MWM because it is
own care. The e l i m i n a tio n of p a i n m a n i fest w i t h
e a sier to p e r for m both in the clinic and at home than
M W M is also expected to fa ci l i t ate comp l i ance
i so me t ric wrist and fmger extens ion
with therapy as t h e patient is able to
.
[n m a ny cases. using a MWM that involves gripping will subsequently relieve the pain on i s o m e tr ic wrist and
fi n ger e).1:ension. This was n ot the case with
Howard , al tho u g h the pain with isometric wrist and
O utco m e
results. This ability to t h i n k
ac ross
see
immediate
t i me-s i mu l t a
n e o u s l y i n t h e p a s t . presen t a n d ru tur(:,� is reflec
tive of higher order c o g n i t ive a b i l i ties ty p i c a l o f the ex p e r t c l i nici a n .
discomfo r t but felt no need
to carry on w i t h h i s se lJ
mobil ization n o r a ttend [o r fu rth er treatment. In the D u ring a fo l l ow-up tele p h o ne c a ll 1 mo n th l a ter,
l i g h t of this o u tcome, no fu r t h e r apP O i n tments were
Howard said h e b a d e x p e ri en ced occasional minimal
necessary.
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6 A C H RO N I C CASE OF M E C H A N I C ' S E L BOW
R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R E A S O N I N G C O M M E N TA RY
D
Do you expect that further episodes will
and t i ssu e breakdown. Carefu l attent io n has a lso been
occur?
paid to p otent i al contributing fa ct o r s such as work te c h n i q ue. prevention o f overus e and overload. mainte nance of su pin ator eccentric control. and the patien t s
• Clinicians' an swer
'
active participa tion in his own managemen t . all of
wh ich may hel p to minimize recurr e nce of his p a i n
If t h e p a t i e n t c a r ries on w i t h h i s exerci se progra mme. it
.
is u n l i kely l h a t he w i l l h ave a re t u rn of h i s l a teral elb o w p a i n . However. i t is much more I U<e ly t h a t he w ill sto p d o i n g the exercise. It is a l s o p robabl e t h a t he w i l l under
• Cli n i cal reasoning c o m m e ntary
la ke work a c t iv i ty in t he fu ture t h a t invo l ves overuse or u n acc ustomed use of the pronator and w r i s t and fi nger ex tensor m u scles.
a nd
The prognostic hyp oth esis here is guarded d es p ite
which m ay ca u se a retu r n of his
the excellent outcome to manual ther a py. The p oss i
sym p t o m s . Hav i n g had one incident of p a i n related to
bility that the patient will c ease self-management
this type of activity p rob a bly p red i s p oses h im to future
a nd u ndertake ill-advised work activities is r ecog n ized . However. the broad and h olis t i c approach to management. which includes ed u ca ti o nal and ergo nomic interventions . is acknowledged as h a vi ng a p os it i ve influence on the patient's prognosis. From this re spon s e it would appe ar that experience-based
episodes . p a r ti c u l arly if
n o rm a l h umerouLn ar and
radiohumeral bone a l ignment is not m ai n t a i ned . If he ex p eri en ce s a si gn ifica nt nare- up. home exerc ise alone may not be su fficient to relieve his pain and he wou ld need to re tur n fo r fur ther treatment.
.
In t he patient's favour a t this po i n t i s the fact that he
person al knowledge has somewhat i n fluenced this
has been educ ated about his cond i t i o n and n o w u nder
c l i nical reasoning d ecisi on An understanding of the
stands the i mp o r tan ce of seLf-mcmagement . Howard is
various d em a n d s and priori ties in a p ati e n t s life is
.
'
aware that his prob le m o rigin ated from un a ccust ome d
largely ac q u ired from. a nd
use of the forearm musc les. le adi n g to ab n o r ma l forces
ated from. the perspective of one 's own personal
around the elbow and s ubs eq uen t j O i n t malalignment
experience of similCir situations.
can
o nly be truly appreci
• Refere nces A l l a n d e r.
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some common rheu matic d i seases
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0['
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Institute of Health Sciences . Cifford . L . S . a n d
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tension in the m ed ia n nerve: po ssi b l e
epi c o ndy l iti s i n the
i m p l ications for the upper l i m b tension
S p orts Medicine. 1 5 . 2 8 3-3 0 5 .
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Mack.
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P l ane View Press.
Nirschl. R.P. and Pe t ron e . F.A. ( 1 9 79 ) . Ten n i s e l bow. Journal o f Bone a n d JOi n t S u rgery 6 1 A . 8 3 2-8 3 9 Noteboom. T. . Cru ver. R Keller. J . e t a l . .
. .
Putnam. M . D.
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Reid .
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A na tomy and
H i s tol ogy. 3 8 6 .
3 1 7- 3 3 0 .
B . a n d Wright. A . ( 1 9 9 5) . Effects o f a novel m a n i p u l a tive p hys i o t hera p y tec h n ique on te n n i s elbow: A s in gle case stu dy. M a n u a l T h e ra py. 1. 3 0-3 5 . Wadsworth. T. G. ( 1 9 8 7) . Te n n i s el bo w :
Vicenzino.
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Bri ti s h M e d i c a l J o u r n a l .
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O l i ver. M.J. ( 1 9 8 9 ) . A bio mec han ic al basis
T h e rap i s ts Assoc i a tion of Australia
a p pr o ac h to management of
for classifi cation of movem e n t patterns
( B . A . Da lziel a nd J . C . S nows i l l eds . )
muscu loskeletal p a i n . [ n P hys ic a l
i o co mb i n ed Olovements examination
pp. 79-90. Mel b o u r ne: M an ip u l a t i ve
T hera py of t h e Cer v ic a l a n d Thoracic
.
of the spine. In P r oceed i ngs of the
Sixth Bien n i a l Con feren c e of the
In P roceed in g s of the F i fth B i e n n i a l
.
T h e rap i s ts Associa tion of Au stra l i a .
S t roya n . M. and W i Uc K . E. ( 1 9 9 3 ) .
Ma n i pu l ati ve Therapists A sso c ia tio n of
The fu nc t i o n a l a n a tomy o f t he e l bow
White. S . G . a n d S a hrman n . S . A .
Spine. 2 n d ed n ( R . Grant. e d . ) p p . 3 3 9-3 5 7. Ed i n b u rg h :
Churc h i ll
L i v i n gstone.
A u s tra l ia pp. 1 3 8- 1 4 5 . Mel bourne:
c o mpl ex . Jou r n a l of O r t hoped ic
M a n i p u l a tive Therapis ts A ssociat i on of
and Spo r ts PhYSical Therapy. 1 7 .
te nsion in th e n e u ra l system :
Austra l i a .
2 79-2 8 8 .
A pre l i m i na r y study of te n n i s e l bow.
Plancher. ICD . H a l brec ht. J . a n d Lourie. G . M . ( 1 9 9 6 ) . M e di al and l a teral .
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H . K . a nd Sarkar. K . ( 1 9 8 0).
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Copyrighted Material
Ya x l ey. G. and J u l i . G. ( 1 9 9 3 ) . A dv ers e
Austra lian Jour n a J of P hysiotherapy. 3 9 . 1 5-2 2 .
Chronic low back and coccygeal pain Paul Hodges
�
SUBJ E CTIV E EXAt:!!",ATION
Skye is a 39-year-old fem ale hig h sch o o l teacher who
most comfortable position was supine lying, and as
presented with a 6-month h istory of lower b ack and
such she h a d n o night pain or sleep disturbance. Skye
coccyx pai n . She had no referra l of pain laterally into
was rela tively pain-free in the morning. but her pain
her buttocks or i nto her legs a nd no anaesthesia or
prog ressively increased du ring the day. At times, she
paraesthesia. T he pain had d eveloped gradua lly over
needed to rest i n supine lyin g in t h e middle o f t h e day
a period of 2 m o n ths with no identifiable cause. There
in order to relieve her back p ain. She had difficulty in
was no history of direct trauma to the coccyx (e. g. fall
si tting throu g h long meetings and h ad to ch a n ge
or childbirth) or of prev i ous lumb ar, thoracic or lowe r
position regularly. Her work colleagues were aware of
lim b p a i n . S h e was gene rally fit and well with no
her condi tion and were suppor tive. Her main recre
neuro logical , respiratory. gastroenterological . gyn ae
ation a l activ i ties were read ing. swimming . socializing
cological or other musculoskeletal disorders. including
and travel. She was able to position herself comfor t
no change in bladd er or bowel fu nction as ascer
ably to read a n d swim m i n g did not provoke her symp
tained thro ugh general screenin g q uestion s . Prior to
toms. However, she found it difficult to meet people
her initial physiotherapy consultation S kye h ad con
socially because this generally involved either pro
su lted an orth opaedic surgeon. who performed a coc
longed Sitti n g or prolonged standing, which invari
cygectomy. This d id not result in any cha nge to her
ably were u ncomfortable. Therefore, she had limited
symptoms postsurgery. Fu nctionally. Skye was able to
her social interaction because of the pain. In add
continue to work with mod i fica tion to her routine
iti o n , she lived alone and was now depressed about
to a llow frequent changes in positio n . but she had
her p resent situation. She was also concerned that
required several days off work because o f pain.
she may not be able to travel long distances again
Following the surgery, a friend had recommended she
because o f her in ability to sit for long periods.
start swimming three times per week. S h e had done this and was now relatively fit.
Skye felt angry and disappointed tha t the removal of her coccyx did not resolve her pain. She felt she had
Skye's main complaint was an inabil ity to sit o r
been let down by the orthopaedic surgeon. who had
sta nd for periods greater than 3 0 minutes as a result
provided
of centra l pain in the coccyx and lower l u mbar spine
Following the failure of the first surgery, it was recom
area. Her pain was also incre ased by o ther sustained
mended to her that she have a revision of the surgery
a
simple
explanation
for
her
problem.
positions, such as lumbar Oexion. She generally sup
and removal of fur ther tissue. However, Skye felt that
ported herself using her a rms if she had to sustain a
this was unlikely to help and declined to h ave fur ther
position for any duration and o ften her pain would
surgery. She had accepted that she would h ave pain
increase after returning to the neutral position. Her
forever and was concerned that she might 'end up in a
Copyrighted Material
103
C LINICAL REASONIN G IN ACTION: CASE STU D IES FROM EX PERT MANUAL THERAPISTS
wheelchair'. It was clear that she had no understanding of the complex nature of chronic pain or of the concept of pain referral and was not cognisant of any alterna tive explanation for her symptoms. Furthermore, she
was unaware of what physiotherapy could olTer but reduce her pain. Her ultimate goal was to become completely pain-Iree and unrestricted in her recreational activities and travel . was willing to try anything to help
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
D
What were your initial thoughts at this stage? In particular, what hypotheses were you considering with respect to the source of the symptoms/ impairments and the pain mechanisms involved?
• Clinician's answer
resulting in repetitive irritation of spinal structures. Regardless, it would be important to consider cha n ges in the central nervous system perception and inter pretation of pain.
D
Did you consider that there were any significant psychosocial factors in the patient'S
My initial impr ession of this patient was that the coc cyx was probably not the primary source of her symp toms. This was largely based on th e fact th at there was no provocative episode related to the onset of her symptoms and that most of the painful positions and
• Clinician's answer
movements would be unlikely to impact on the sacro coccygeal area. In particular. the failure of the coc cygectomy to alter the pain suggested that it was probably not the source. There were several other options that required consideration. The location of the pain was consistent with possible somatic referral from the lumbar spine or sacroiliac joints. In addition. it was anticipated that the function of the deep trunk muscles may be compromised as a result of the pres ence of pain. This was hypothesized because research evidence has indicated that such a change is a rela tively constant finding in people w ith low back pain (at least of insidious onset) (Hodges and Richardson , 1996) and these changes can be induced by experi mental pain (Hodges et aI., 200la). On the basis of the mechanisms that increased and decreased her symp toms (such as sustained nexion) and the insidious onset of her pain, it may be reasonable to suspect disc pathology, but this is difficult to conHrm. Because of the 6-month duration of her symp toms, Skye had moved into a chronic pain state and as such it was likely that peripheral sources of her symp toms may be reduced and central pain processes are now involved. Several factors further complicated this issue. such as her depression , catastrophizing beliefs and the reduction of her leisure activities as a result of pain. However, local processes could not be excluded. particularly if the maintenance of her pain was caused by movement dysfunction/impairment,
There were several potential psychological factors that may have inl1uenced Skye's presentation. The major factor was a feeling of loss of control and uncertainty. This was compounded by the failure of the initial sur gery, which had promised a simple solution. Skye was also fearful for her future and had belieL, regarding the probable course of her symptoms (e.g. 'end up in a wheelchair'). She was also depressed that her social interaction and opportunity to travel were limited by the presence of pain. There is considerable evidence in the literature to suggest that mood and emotion have a significant effect on pain perception (Weisenberg et aI., 1998; Zelman et aI., 1991). Therefore. it was con sidered important to attempt to deal with these changes both directly and indirectly. It was planned to use t hree main strategies to deal with the psychosocial issues. The IIrst was to provide adequate education about the nature of low back pain and changes that arise when pain becomes chronic. Related discussion would also be needed to deal with expectations and misconceptions. The second was to give her back control of her situation and make her responsible for her recovery. Tal<ing an active approach to management (predominantly involVing exercise of the trunk muscles and restoration of trunk control) was considered essential for this to occur. Finally, it was planned to assist with the resolution of these fac tors by listening, providing support and encourage ment, and answering her questions.
presentation? If so, how did you plan to address these in your management?
Copyrighted Material
7 CHRONIC LOW BACK AND COCCYGEAL PAIN
• Clinical
reasoning commentary
experience
( i.e .
the psychosocial
issues
discussed):
questions c le a rly demon
physical impairments and associated sources (e.g.
strate the breadth and depth of the clinical reason
ing of the expert clinician. despi t e it being only early
lumbar disc): factors contributing to the mainte nan ce of the problem (e.g. d e ep trunk muscle dys
in the
function/impairment):
The responses to th es e two
c lin ic a l
encounter.
Notably, specillc and
detailed hypotheses have been generated in
a
num
and
management
(e.g.
exercise ) . This ability to consider m ultiple hy poth e
ber of categories. including activity/participation
ses in multiple categories simultaneously is evidence
(e.g. ce n
of highly developed skills in the cognitive processing
restrictions: pathobiological mechanisms tral p a in
tE
processes):
the patient's perceptions of her
of clinical data.
PHYSICAL EXAMINATION
General observations
buU( of the extensor muscles in t he l umbar region.
Skye had poor posture in sitting and s tanding . with
There was a lso hypertrophy of the hamstrings and
a general appearance of having what is commonly
wasting of the gl uteal muscles. Activity of obliquus extern us abdominis (OE) was apparent at rest in stand ing and sitting. T his activity of OE was modulated with respiration, indicating a con tr ibution of OE to expir ation ( w hich is normally passi ve and dependent on
descr i bed cli nica l ly as 'low tone'. Her posture was slouched w ith
a
m a rked cervicothoracic kyphosis,
rounded shoulders and upper cervical extension with a 'poked' chin. In standi n g she had a long shallow lumbar lordosis extendin g to the mid-thoracic level.
elastic recoil of the lungs and chest wall). In conj unc
anteriorly shifted pelvis th at was positioned in pos
tion with Skye's kyphosis was a recessed lower rib cage
an
terior pelvic tilt and hyperextended knees. In many
(that narrowed w ith expiration) and
positions, she re lied on using her upper l i mbs to hold
lower abdomen. Relaxed breathing predOminantly
herself upright. The thoracic erector spinae were
involved the upper chest with activity of the accessory
hypertrophied and there was an obvious reduction in
i nsp ir atory muscles.
a
protruding
REASONING DISCUSSION AN D CLINICAL REASONING COMMENTARY
D
What was your interpretation of the postural
of this activity and expiration should be a passive
and breathing pattern, and its Significance to
process generated by the elastic recoil of the lungs
and rib cage (De Troyer, 1996). In tasks in which res
your managemen t?
piratory demand is increased, acti v ity of the abdomi nal muscles wiJI normally occur during expiration to
• Cl i ni c i an 's answer
assist with expiratory airflow (Agostoni and Campbell,
Several recent studies have hig hlighted the coordin
1970). If the in creased drive for respiration is invol
ation between the diaphragm and deep abdominal
untary (e.g. increased concentration of carbon diox
muscles ( particula rly TA)
ide). the respiratory modulation of abdominal muscle
[or respiration a nd postura l
c ontrol (Hodges et aI., 1 997a : Hodges and Gandevia.
activity should frrst occur in TA, then the other
2000a). In norma l relaxed stand ing , there should be
abdominal muscles (De Troyer et aJ., 1990).
low l evel tonic activ i ty of TA (De Troyer et al.. 1990:
When the diaphragm contracts to prod uce ins pir
Coldman et al .. 1987: Hod ges et a!.. 1997b): however,
ation. there should be both
there should be no or minima l res piratory mod u lation
of the abdominal wall and a bi - bas a l expansion of the
Copyrighted Material
an
anterior displacement
I.
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
rib cage (as a result of the vertical pu l l of the costal
the lumbar spine and m otio n at t he tho racolumbar
fibres of the diaphragm an d the bucket-h and le action
junc tion and r ib cage (Gurfinkel et aI., 1971)). Recent
of the ribs (Mead, 1979)). For examp le , durin g normal
data i n dic a te that the n ormal postural compe nsatio n
'
'
relaxed res piratio n there should be abdomin a l wall
[or respi ration involves subtle movemen ts of the spine
disp lacem e n t bi-basal expansion of the rib cage, min
and pelvis (Hodges et aI., 2 0 0 2 a) but this compensa
imal upper chest movement and no or minimal respira
tion may be inadequate in people with low back pain
tory activity of the abdominal muscles. When the
(Grimstone and Hodges, unpub l ished data). Al terna
,
,
d eman d [or spi nal stab ility is incre a sed (for ex ample.
tively psychol ogical fac tors, such as those commo nly
durin g repetitive limb movement) the d i aphr agm and
aSSOCiated with chro n i c pai n. may prod uce c h anges
Tt\ should co-con trac t . with recip r ocal changes in
in breathing pattern. Stud ies have i n d icated that pos
amplitude of ac tivity to sustain intra-abdomi nal pres
t ural ac tivity of the trunk musc les may be affected
,
su re and respiration co ncurrently (concentric con
by stress. fear and atten tion demand (Moseley and
traction of the diaphragm and eccentric contraction of
Hodg es 2001).
TA [or
inspiration and t he converse for expiration)
(Hodges and Ga ndevia. 2 000a b ) ,
sible i m plicati ons for muscle functio n and moveme n t
.
In S kye there was unex pe cted activation of OE ,
with
.
Ther e are several postu r al fac tors tha t ha ve pos
expiration (rib cage depressi o n and obvious
charac teristics. which need to b e confirmed with fur t her examination. First, Skye's general ap pearance of
muscle ac tivi ty that was mo d u l ated with resp i ration).
hav ing 'low t one m ay h ave sever a l i mplications for
no tonic activity of TA ( prot r u d i ng lowe r abdomen)
the aetio logy of her pain and its management. It has
'
and a reduct i o n in the norm a l pattern of diaphragmatic
been rep orted that minor coord ination deficits are
breathing (reduced bi-basal expansio n. increased
common in people with chronic low bac k p a in lJ a nd a,
upper chest breathing). As a resu l t . most respira tion
1978). T he general appearan ce of low tone is consis
occurred in the up per chest. The redu ction in bi-basal
tent with this proposal and su ggests
exp ans ion is IU<ely to be at least par tly a re su l t of the
have had poor muscle control over an extended period.
that Skye m ay
activity of OE. whic h l i mits rib cage expansi on. These
In ter ms of management. the likely p rese n ce of coord
signs suggest t h at the normal co ordination of respira
ination deficiencies and the duration of these changes
tion and postural control may have been compro
would have rami ficatio ns for the elTicacy and speed
mised and there is excessive use of the superficial
of re-education of function of the trunk muscles.
abd ominal muscles. Clearly. more spe c i fic assessment
Secondly. Skye's stand i ng posture and changes in
of the function of TA and the other abdominal mus
muscle bulk sugges t that she relies predominantly
cles is needed to confirm this observation. No study
on the l ong thoracolumbar erector spinae and super
has yet conftrmed a rela ti o nsh ip between these changes
fic ial abd o m i n al musc les to move and control her
i n r esp i r a t ory p attern a n d back pain. but clinically
spine . Although contrac tion of the lumbar erector
it appears to be a common find i ng
Furthermore.
spinae and superfiCial mu ltifi dus can produce and
experi mental ly induced acute pain has been shown
main tain the lu mbar lord osis (Bogd uk, 1997). when
.
to produce changes in r esp irato r y fu nction (Tandon
the thoracolumbar erector sp i n ae muscles contract
et aI.. 1997).
they produce thoracolumbar extension. The motion
The mec h ani sm for such changes is not known but
at the mid-lu mb ar and thoracolum bar regions may
it could involv e bo t h physical and psyc hologic al
be increased, placing stress on the passive elements in
mecha nisms. For insta nce, the c hanges may resu l t
the lumba r spine. This finding is consistent with the
from in creased activity of O E attempting to compen
changes in resp i ra tory patter n and requires rurther
sate [or poor TA contro l. or alterations in movement
i nv esti gati on
coordination by the central nervo us system as a resul t
,
Therefore, the resp iratory and po s tural parame ters
of pain, which then causes i ncreased activity o f OE.
of Skye s presentation provide an i ndicat i o n that the
Seve ral studies have shown inc reased activ i t y of spe
fu nctio n of the d eep tru nk musc les may be comprom
'
cific trunk muscles fo l l OWing experimentally i n d uced
ised, Altho u g h further specific evaluation would be
pai n (Arendt-Nielsen et aI., 1996; Hodges e t aI.,
r equired to conl1rm these o bservations. they provid e
2001a). The cha n ges in resp iratory pattern may also
preliminary evidence of several fac tors that may need
occur in an attempt to l imit motion of the sp i ne (nor
to be considered in the re tr ai ni ng or the d ee p mu scle
mal diaphragm atic resp i ration involves extension of
functio n
Copyrighted Material
.
7 C H RONIC LOW B AC K AND COCCYGEAL PAIN
• C lini cal reason ing commentary
'hi
observation) and p ersoo a l---c an be Linked in the con
The very det a i le d response regarding posture and
text
breathing. in conjunction with the consideration of
meaning and accessibility in the clinical setting. This
psych osoci al aspects
linki ng rurther enriches the clinician's know ledge base
above,
nicely i llustrates how the
or real-lire patient problems. thus enhancing
three types of knowledge-propositional (e.g. st.udies
th rough the development or
highlighting the coordination bet ween t he diaphragm
zation. As in this
and deep abdominal muscles for
and management of clinical problems requ i res
tural control). professional craft
organization of all three types of knowledge.
respiration and pos (e.g. skills in postural
Assessment or the pe l vis indicated a sl ight ly higher
case.
a
higher level or organi
the successfu l understa n ding
a rich
unremarkable. Palpation of the structures around the
iliac crest on the right side and increased anterior tilt.
lumbopelvic region was undertaken
In a ddition . Skye had hyperextended knees and elbows
picture of the patient's presentation. Piriformis was
and was generally hypermobile (she could approxi
found to be tender bilaterally.
mate the lateral side of her thumb
people
to her forearm and extend her I1ngers to become parallel with h er wris t) .
as
to gain a general
it commonly is in
with low back pain.
Mus cle function examination Movement examin ation
The function of the deep trunk muscles was assessed
All movements 01 the lumbar spine were of greater
following initial attempts to teach Skye to contract
than average range of motion. Pain was reproduced
transversus abdominis (TA) independently from the
in the lumbar spine at the end of range of extension.
superl1cia l abdominal muscles, and the deep fibres of
lateral flexion to both sides and lateral gliding of the
multil1dus independently from the long erector spinae
pelvis in eith er direction. Lateral gl i de of her pelvis to the
and superficial I1bres of multifidus. P rio r to perform
right gave the most accurate reprod uction or her lum
ance or the test, it was necessary to educate Skye as to
bar spine pain. Pain remained briefly alter returning to
the anatomy and function or TA (Fig. 7.1) and the evi
the neutral st anding position. Trunk flexion in standing
dence which suggests that the function of the de ep
and on hands and knees predominantly involve d move
muscles may be impaired in patient s with low back
ment in the regions or the thoracolumbar junction and
pain. She was then pos i tioned in [our-point kn eeling
mid-lumbar spine.
with a lesser degree of movement in
and instructed to relax her abdomen. She had diffi
the low lumbar spine and hips. Minimal intervertebral
cul ty relaxing her OE completely in thi s position and
movemen t or t he lower lumbar segmen ts was observed
experienced discomfort in her elbows. which were
with trunk movement in the sagittal plane. In rour
hyperextended. The el bow pain was resolved b y pos
point kneeling . she was unable to control the position of
itioning her with the weight of her upper body supported
the lumbar spine when moving backwards with hips towards the feet. This movement resulted in consid er able flexion at th e thoracol umbar juncti on.
Passive jo int movement examination and palpation On passive movement examination of the spine and pelvis, there was increased resistance to central pos teroanterior pressures at the L4 and L5 ver t ebra l levels. Sustained posteroanterior pressure on L4 ror more than 10 second s resulted in reproduction of the coccyx pain. Posteroanterior pressures applied to the upper
Fig. 7.1
lumbar levels were norma l or
the anatomy of transversus abdominis and the performance
had slightly increased
mobility. Unilateral posteroanterior pre ss ures were
Diagram shown to patient to demonstrate
of an independent contraction of this muscle.
Copyrighted Material
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
(�,...-----� Fig.7.2
Diagram shown to patient to demonstrate the
technique for palpation of contraction of transversus abdominis and how to detect through palpation whether the contraction is correct.
on her forearms. She was instructed to breath in and out and then gently and slo wly draw her lower abdom inal wall up an d in. Skye found this task difficult, and on observation it was apparent that most of the move m en t of her abdomen occurred in the upper half and
her rib cage was depressed downwards and inwards.
Both of these signs indicated that she had pre domi nantly contracted her OE. Findings from palpation of
Fig. 7. 3
Test for independent activation of transversus
abdominis without contribution of the superficial abdominal muscles. The patient lies prone with
an
inflated
pressure cuff placed under the abdomen. Contraction of transversus abdominis lifts the abdominal wall up off the cuff, resulting in a reduction in the cuff pressure. The normal response is a decrease in pressure of 4-6 mmHg. which can be held for 10 seconds and repeated.
the lateral abdominal wall and surface electromyogra phy recordings from electrodes placed over the distal end of the eighth rib conrlrmed the presence of exces sive OE activity during the performance of this task. With palpation of the abdomina l wall medial and infe
rio r to the anterior superior iliac spine (ASIS) there was no discernible contraction of TA (deep tightening) (Fig. 7.2) and only superficial contraction of obliquus internus abdominis. To assess the con tractio n of TA more formally, Skye was positioned in prone lying with an
,
air-ruled cuff (Stabilizer. Chatt an ooga USA) pl ace d
under her abdomen (Fig. 7.3). When Skye atte mpte d to per for m the contraction in this position, she was unable to reduce the pressure but instead increased it from 70
to 72 mmHg. This pressure change wa s associated with the signs of superHcial muscle activity outlined above. Following education pertaining to the anatomy and
function of multifidus, Skye was taught to contract the lumbar
multifidus isometrically. Palpation of the back
muscles and multifidus revealed rigid superficial ten dons of the long erector spinae. The bulk of lumbar multifidus was generally reduced but eq ual between the left and right sides; it had a thickened consistency that lacked the normal elastic feel of healthy muscle ti ssue at the L4-L5 and L5-S1 levels. Attempts to contract the
Fig.7.4
Test for independent activation of the deep
fibres of multifidus without contribution of the superficial erector spinae muscles. The therapist palpates for a gentle slow increase in deep tension in the multifidus while the patient performs an isometric contraction of the muscle.
pelvic tilt co mbi n ed with contraction of the oblique abdominal muscles. The pressure in the in11ated cuff under the abdomen was increased in response to the activation of the oblique abdominal muscles.
Muscle length tests m otion
found on muscle leng t h tests
multifidus (Fig. 7.4) revealed an inability to perform this
The ranges of
task. which she simulated by performing a posterior
for rectus femoris and iliopsoas were
Copyrighted Material
m o der a tely
7 C H RON I C LOW BACK AND C OC C Y G EAL PAIN
'h'
restricted and equal between sides. Measurement of
lumbar or coccyx pain. The straight leg raise evoked
the length of the hamstring muscles was undertaken
only
in two ways: passive stTaight leg raise and active exten
above).
a
stretch pain in the posterior thigh (as described
sion of the knee with the hip held in 90 degrees of nexion. Both tests revealed limitation in the range of motion (approximately 45 degrees of hip nexion with straight leg raise and 40 degrees short of full knee
Ad j acent joints No pain or movement dysfunction/impairment was
extension with the hip held in 90 degrees of flexion)
found in the hips or knees with active and passive
and stretch pain in the posterior thigh that was not
movement tests. Pain provocation tests of the sacro
increased by passive ankle dorsiflexion.
iliac joints and pubic symphysis were negative.
Exami nation of n eurodyn ami cs
Neuro l ogical exami n at i o n
There was n o asymmetry i n range o f motion o f straight
Nothing abnormal was detected on examination of
leg raise or prone knee bend and no reproduction of
reflexes, muscle strength or sensation.
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
D
What factors do you consider have contributed to the onset and perpetuation of the patient's symptoms! Can you please explain the
1995; Wilke et aI., 1995). Contraction of TA and eleva tion of intra-abdominal pressure have been shown to
mechanism(s) by which each factor has
increase segmental stiffness of the spine in humans
contributed to the pathology!
• C l i n i c i an 's
particularly around the neutral pOSition (Kaigle et ai.,
(Hodges et aI., 200lb,c) and pigs (Hodges et al., 2002b). In addition, TA has been found to be active in a manner
an swer
that is consistent with stabilization of the spine, but
Skye has several factors in her presentation that may
unrelated to torque production (Cresswell et aI., 1994;
have contributed to the onset and continuation of her
Hodges and Richardson, 1997). Furthermore, changes
pathology. rirst, the changes in the activation of the
in the function of these muscles have been identified in
deep muscles are theoretically consistent with continu
people with low back p ain (i.e. delayed onset of TA activ
ing instability and irritation to the lumbar structures. It
ity with arm movement tasks (Hodges and Richardson,
has been argued that lack of an effectively functioning
1996) and decreased fatigue resistance of multifidus
deep muscle system would predispose the trunk to con
(Roy et ai., 1989)). While it is dil'ficult to obtain direct
tinued microtrauma (Gardner-Morse et aI., 1995). It
evidence to show that the change in function of these
is not possible to determine whether the poor activity
muscles leads to jOint injury/microtrauma by inad
of the deep muscles was present prior to the onset of
equate support of the spinal structures, it is hypothe
Skye's pain, but her presentation of poor coordination
sized that this may be the case.
and poor posture suggests a long-standing history of
Instability is a continuum of change in interseg
poor movement control. It is impossible to ascertain
mental control. At one end of the spectrum is gross
whether the change in muscle function was respon
instability resulting from major disruption of the pas
sible for the initial development of pain; however, it
sive structures (e.g. spondylolisthesis, burst fractures)
could be a contributing factor in the continuation of
(Panjabi et aI., 1995). At the other end of the spec
her symptoms.
trum is poor control of intersegmental motion within
There is considerable evidence that TA aDd multi
the normal range of movement, and particularly
fidus are important for segmental stability of the spine.
around the neutral position, as a result of minor dis
In animal models and in vitro human studies, simula
ruption of passive structures (e.g. minor tear of the
tion of multifidus contraction has been shown to
annular fibres of the intervertebral disc) (Panjabi,
increase stiffness of the spine and control motion,
1992). From her presentation of pain in sustained
Copyrighted Material
I
CLINICA L REA SON I NG IN ACTION: CAS E STUDIES F RO M EX PERT MANUA L T HERA P I STS
mid -range positions and lack of frank traum a , Skye is likely to fall i n to the latter group. This theoretical construct has derived some d irect su ppor t from bio mech anical models of the spine. Several authors have argued that an operational deep muscle system is esse n tial for main tenance of suppor t of the spine (Cholewicki et aI . , 1 9 9 7 : Gardner-Morse et al.. 1 9 9 5 ) . O n this basis, i t seems feasi ble that one factor con tributing to the perpetuation of (and perhaps even causing) Skye 's symptoms m ay be the poor contro l of spinal stability. Although we cannot (yet ) directly measure in the clin ical setting the fu nc tion of TA and multi fi d u s i n stabilizing the spine, we can ga i n some indirect indi cation of function/ dysfu nction via the hollowing test wi th the pressure cuff placed under th e abd ome n . T here is initial evidence that the abi lity to perform this test is related to the tim i ng of TA in a task that challenges postu ral con trol (Hodges et a t . . 1 9 9 6) . Second , several postural/ergonomic fa ctors present as poten tial con tTibuting factors to the onset and /or
• Clinician 's an swer The main features of Skye's pain that were suggestive of cen tral sensitization were that the pa i n had out lasted tissue healing time, it was sometimes unpre dictable, pain and relief from treatment were laten t , a n d the pain was associated with anxiety and depres sio n . The ev idence from S kye's presen tation tha t was inconsistent with this proposa l was the strong correl ation between physical signs and her pain. For instance, it was possible to reprod uce her symptoms by perform ance of a simple physica l test . Many other factors of her presentation (e.g. change in movemen t pa ttern , pain-reproducing manoeuvres) were also consis ten t with a peripheral source. In the case of Skye, it is crit ical to consider that peripheral and cen tra l chan ges are not exclusive and elemen ts of both can be present. In fact the combin ation of peripheral sensitization and cen tral adaptations that ' upregulate' the response o[ the system to pai n
are
likely to be equ a l ly im portant.
perpet uation of Skye's symptoms. For instance, her poor posture in sitting (increased lum bar l1exion ) and
What was you r primar y hypoth eSiS at this
standing (thoracolumbar exten sion) is likely to lead to
stage regarding the source of the patient's
excessive strain of the in tervertebra l discs and other
symptomslimpairments (e.g. back and coccygeal
lumbar stru c tures through increased i n trad i scal pres
pain with prolonged sta nding or Sitting) and the
sure ( N achemson and E l fstrom, 1 9 7 0 ) and creep in
associated pathobiological mec h anism(s) ?
vi scoelastic passive tissues, resulting from sustained
What clinical findings support and negate this
tension at t he end of range of lumbar l1exion. In
hypothesis?
additio n , Skye's poor posture is associated with changes in
the movemen t pattern of
the h ip-lumbopelvic
region , which may lead to increased stress on lumbar
• Cli n ician's answer
spine structures. Skye has compensated for the reduced
The
use of hip and lower lumbar movement by increasing
symptoms was'pathology at the L3-L4 lu mbar motion
primary
hypothesis
[or
the
source
of
the
the motion in the mid-lumbar and thoracolumbar
segment resulting [rom a combi nation o f poor control
regions. This increased movemen t may be responsible
of spinal movemen t , generalized hypermobility and
for increased stress on the lumbar segments and could
ergonomiC or postural factors. From t he evaluation , the structures involved could be either the interverte
potentially result in repeated microtrauma. Third , there are psychological factors that may be
bral disc or the zygapophyseal joints. Lack o[ changes
maj or issue has
in sen sation', muscle strength, rel1exes and the absence
been her disappOi ntmen t that removal o f her coccyx
of pain referral to the leg indicate that spinal nerve/
con tribu ting to her presentatio n .
A
not alleviate her
nerve root com promise was probably not a factor. The
pai n . This has lert her feeling helpless and frustrated,
principal location of the symptoms i n t he coccyx area
and pessimistic about her chances of recovery.
could be explained by somatic pain referral.
D
In a previous response, you mentioned that
inner two-thirds of the intervertebral elisc, pain is more
the chro n i c nature of this patient's problem
likely to arise from trauma to the annular fi bres a nd
( ' the cause of her symptoms ' )
did
Because of the absence of sensory innervation of the
suggests that central pain mechanism processes
associated inl1ammatory processes (Bogd uk , 1 9 9 7) .
would be li kely.What features in her
Several factors [rom Skye's clinical presen tation were
presentation specifically supported or negated
consisten t with the disc hypothesis. First , reproduction
a pathological centra l pain mechanism?
of Skye 's pain was achieved by centraJ posteroanterior
Copyrighted Material
7 CH RON I C LOW BACK AND COCCYGEA L PA IN
pressure to the L4 leve l . Secondly. on examination of
completely excl u d e coccygea l path ology as t he pres
the movement patter n. the L 3-L4 level was identified
sure could mechanically a ffect the sacrum.
as the region of transition between an area of decreased mobility ( lower lumbar segments) and the mobile u p per
The sacro il i a c jOint
a lso
presented as a poten t i al
source of the sympto m s , through p a i n referra l . The
could
provocative positions of Sitting and standing both
result in increased stress on the passive elements at t h e
place stress on the sacroil iac joint from torsional forces
lumbar
spine/ thoracol umbar j unction.
This
L 3 -L4 level. Thirdly. the insidious onset of her pain is
be tween the sacrum and i l i a . In the ftrs t ins tance, this
consistent with the commonly described clinical pres
hy pothesis was rejected a s the pain was located cen
entation of disc pathology. F i n ally. the provocative posi
trally and was not elicited with basic pain provocation
tions and movements. particu larly sustained Sitting and
screeni n g tests o f the sacroiliac j o i n t ( for a review of
trunk Ilexion. are consistent with activities involving
these tests see Lee.
increased stress of the i n tervertebral disc as a res ult of
fa iled to resolve with the initial treatme n t of other
raised pressure and l oad ing.
str uctures . i t might then b e necessary to u nd ertal(e a
The zygapophyseal j o i n ts may also be responsible
1 989).
However. i f the symptoms
more compre hens ive ex a m i n ation of t h i s regio n .
for t he symptoms . Th is hy pothesis is supported by t h e
O f c o u r s e . i t is possible t h a t the periphera l sou rce
finding t h a t p a i n w a s reprod uced b y l a tera i llexion a n d
of S kye 's p a i n may n o l o n ger be p rese n t and the p a i n
extension of t h e spine. botb o f w h i c h cl ose d own the
w a s n o w perpetu ated b y cen tra l c h a nges i n interpret
facet j oi n ts . However. several factors a re i n consiste n t
ation o f norm a l sensory i n fo rma tio n .
with this proposa l . These i nc lude central presentation of the pain. elicitation of symptoms w i th trunk move ment to each side a n d p a i n p rovoca tion with a central pos tero anterior pressure (and n o t with a u n i lateral pressure ) . It i s important to acknowledge t h a t these hypo theses are far fro m water tig ht and there i s l ittle experi menta l evide nce to conftr m the relationship between these c l i n ical com b i n ations a n d d efic i t in a specific struc t u re.
D
• C l i nical
reasoning com mentary
It is clear from the r espo n s e s that the clinician has n ot l i m ited or red u ced his thinking to j u s t mec h a n i c a l sources o f no c i c epti ve pa i n . a l t hough severa l hypot heses are obviously considered under this
catego r y in terms of the su p p or ti ng a n d negati n g evidence. Due t ho ugh t
.
however. i s a l s o given t o
t he psyc hologica l fe atu res o f t h e presentation
(e.g.
feel i n g s of he l ples s n es s a n d fru s trati o n ) and the p o te n tial role o f c e n tral pa in mec h a n isms in the
Are there any other hypotheses you were
mai nten a nce of the patie n t s symptoms. Such '
considering as possible explan atio ns for the patien t's presentatio n ! Why did you consider these less l i kely ?
a
h ol i s tic and comprehensive ap proac h to manage ment fadlit a te s both the c1inicia n ' s a nd the patient's u nderstanding of h er clin ical problem. and should e n h ance the c hances of a succes s fu l treatment
• Cli n ician's answer
outcome. Importantly. the clin ician is also meta
Coccyx pathology was less l i kely as there was no
cogn itively well aware of the limitations of cli nical
mechanical mecha nism for the onset of p a in ( e . g . fal l
structural diagn os e s . Such awareness is critical so
or childbirth ) . Remova l of t h e coccyx does n o t neces
that professional theory is not accepted as sufficient
sarily excl ude tbis poss i bility as there may be ' memory ' of pai n or cenLTal changes may h ave been initiated
e vi de n ce in is own right. Convers e ly in the absence of
and still be present. However, the reprod uction of
a ttemp ting to u nderstand patients and their presen
.
h ard evidence. clinicians must use existing theory in
symptoms by m a n u a l pressure to L4 is s u ggestive of
tation s while continually rem ai n i n g both critical and
l u m b ar and not coccyge a l i nvolvement. This does not
open minded toward alternative explanations.
E);ij1mH9·,J9"_
' h a nds on' procedures wou l d be used . However, man u a l tec h niques would be employed to provide i n i t i a l
In coLlaboration with Skye. it was decided to take an
p ai n relief s o t h a t t h e exercises c o u l d be performed
active approach to management whereby m i nimal
o pt i m a l ly. The primary focus o f treatment was to be
Copyrighted Material
CL I NICAL REASONI NG IN ACTI ON: CASE STUD I E S F ROM EXPERT MANUAL T H ERAP I STS
based on S kye tak ing the responsibility to restore the
musc les. The best red u ction o f activity or OE was
fu nction of her trunk muscles so as to improve her
achieved in right side ly i n g w ith a pil low betvveen her
ability to stabi lize and protect her spine. The evidence
knees; however, OE remained somewhat active and
that tra ining of the deep muscles of the tru nk is effec
this activity was mod u lated with res p iratio n . Verbal
tive in the management of certain types of low back
i n s tructions to reduce the a mo u n t of OE activ i ty
pain was discussed, as well as the main assumptions
were unsuccessfu l . Instruction was given in rel axed
underlying this a pproach to management. Time was
d i aphragmatic breathing. With tactile feed back over
also spen t discussing the n a ture of chro nic p a i n . its
her lower ribs a nd abdome n , she was able to inspire
presentation and the problems associated with its
with basal rib c age ex pa nsion and sl i g h t abd ominal
manage me n t . The goa l of the tTa i n i ng progra mme for
w a l l movement. and then expire w h i l e mainta i n i n g
the deep trunk muscles was the restoration of the
OE rela x a t i o n .
i ndepend ent function of the muscles ( R icha rdson
most s uccessfu l ly by allowing her to palpate the
et aI . , 1 9 9 9 ) . The aim of this approach is not to teach
l a tera l aspect o f
peop l e to activate these muscles a l o n e , but ra ther to
OE. A fter several m i n u tes of practice, Skye was t hen
activate the trunk muscles in an i n teg rated
encou raged to
ma nn er
to
Accurate relaxation w a s ac h i eved
her
a b d omi n a l
breath i n
a
wall for activity of
con trol led d iaphra g matic
optimize the control o f t he spine. However. in the ea rly
manner fo r seve r a l breaths , clOd then gen tly a n d
stages, i t is necessary t o perform specific con tractions
s l o w ly d raw her l ower abd o men u p a nd i n . This
of the deep mu scles. so that their s k i l led activation can
i nstruction res u l ted i n
be incor porated into complex fu ncti o n a l tasks .
was instructed to reduce her e frort so as to perform a
a
rapid contraction of O E . Skye
con traction that was j us t perceptible and to perform i t s l o w ly. T h i s a g a i n res u l ted i n s i g n i ficant contraction
• Initial treatment
o f OE.
The i n i t i a l tre a tment i nvolved two applica tions fo r 30
S i nce a l l i nstructions re lated to the abd om i n al wa l l
seco n d s of centra l postero a n terior pressures to L4 at
resulted i n i n a ppropriate contraction of OE a nd no
grade III- ( large a mplitude movement towards the end
palpable contraction of TA , i t was decided to c h a n ge
of ra nge of movement (Maitland , 1 9 8 6 ) ) . Two app l i
the strategy a n d teach Skye to perform a gentle co n
c a t i o n s for
3 0 seconds of right l a teral l1ex ion PPIVMs
traclion of her pelvic noor muscles in an attempt to
(pass ive phy s i o logical i n terver tebral movements) to
fa Cilitate
L4-L5 at grade II ( large ampl i tude movemen t with
con tract the pelvic 1100r musc les s lowly and gen tly and
o u t mov i n g into res istance (Maitl a n d , 1 9 8 6 ) ) were
to concen trate o n the anterior part of the pel vic floor
a
con traction of TA . Skye was in structed to
also give n . Re assessment of late ral pelvic sh ifting to
as if s topping the now of urine. A fter several attempts
the right after each appli c a tion indic ated n o change
S kye was able to perform the con tractio n . When this
or
a
slight increase in her symptoms, a n d no cha nge
in ra nge of motion.
was d o n e i n combi nation with control led breathi ng (prior to the contraction of the pelvic floor muscles ) ,
A ttem pts we re made to teach S kye to perform con
there w a s minimal activity o f O E a n d tightening of TA
traction of TA indepen dently o f the other s uperfici a l
was palpable inferior a nd medial to the ASIS. Once she
abdominal muscles. The two m a i n d i fficulties encoun
had contracted TA she was unable to start breathing
tered were, first, her i nabi l i ty to relax OE, which made
without increasing the activ i ty of OE. To ensure that
it difficult to activate TA independently, and, second ly,
Skye cou l d repeat the same procedu re at home, she
S kye's poor awareness of movement of the abdomi n a l
was shown how to pa lpate the lateral abdominal wa l l
wa l l . E a c h a ttemp t t o perform the contraction was
with t h e right h a n d a n d a lso ta u g h t t o d i s t i n g u i s h
associated w it h strong activity in OE and min imal palp
between contraction o f TA and the oblique abdominal
able tighten ing of TA. Several pOSitions were tr ialed i n
muscles by palpating i n ferior and medial to the ASIS
order to ach ieve t h e greatest re l axation of t h e superfi
with her left hand. A fter three attem pts a t performi ng
cial muscles ( p a r ticu larly OE) and op timal activation
the con tracti on o f TA fo r 5 seconds. she was no longer
of TA . It was a lso necessary to teach Skye to bre athe
able to contract TA successfu lly independ e n tly of the
w i t h o u t co ntraction of OE during expiration. Efforts in
other abdominal musc les. She was instructed not to
fo u r-point kneel i n g , suppor ted standing a nd supine
breathe for the few seconds of the con traction and
lying all resulted in overac tivity of the superficial
that t h is wou l d be inco rporated later.
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7 C H RO N I C LOW BAC K A N D COC C Y G EA L PA I N
It was decid ed that Skye would have a better
chance of achieving the contraction correctly at
muscles and ach ieve our goal of improving the stabil ity of her spine.
home if she was o n ly to perform this exercise and left
Examination of the home exercise re v ealed th a t
contraction of the lumbar multifldus to a l a ter stage.
S kye had difficu lty i n achievin g the correct contrac
No other treatment was impl emented in the first ses
tion in side lying because of overactivity of OE . As a
sion a nd s h e was instr ucted to practise the contrac
result. other positions were t ri a led. S u pported supine
tion of TA ex ac tly as she had been ta u ght three to four
ly ing was tried w ith the trunk elevated on pi llows
time per day for j u s t th ree repetitions. She was
and the elbows supported. but Skye was still unable
advised to retu rn for reassessment in 7 days.
to relax appropriately. The best relax ation of the abdomen was achieved with Skye ly i n g in prone sup
• Second
treatme nt
S kye stated that 30
(1
m i n u tes
ported on her elbows . The tactile contact of her ribs
wee k l ate r)
on the bed gave her ex tra feedback about the move
after the tre atment ses
ment of her ribs and a l lowed h er to identi fy whether
sion her pain was d i m i n i s hed a n d the reduction in
she was using OE to move her rib cage . U nfortunately.
pain l a s ted for severa l d a y s before retu r n i n g as before
this posit ion made it difficult for her to pa l pa te TA
with l i ttle chan ge in i n t e n s i ty or d u ra t i o n . S h e had
since her arms were used for support. As a n a l te r n a
pra cti c ed t h e e x e rc is e s d a i l y and
ti v e .
was
h a p py thai she
had bee n successfu L
a
pressure c u ff wa s p l aced u n d e r t h e abdo m e n t o
provide feed b a c k o n elevati on o f t h e l owe r a b d o m e n .
Reassessme nt of a ctive move m e n ts revealed no
The e x e r c i se i n vol ved severa l control led b re a ths fo l
cha n g e in r a n ge o f motion i n a ny direction . n or
lowed by slow ge n tle contraction of her pelvic floor
in pain prod u c ed at t h e end of ra nge. Pain persisted
muscles. She was s ti l l u nab le to breathe w h i l e per
for a s h o r t period a fter return i n g to the neutra l posi
forming the contraction w i thout increasing the activ
tion. as had o c c u r red d u ri n g the i n itial consultation.
ity of O E . It was reinforced to Skye that the exercise
Passive joint move ment examination
resist
was aimed at p r ecis ion and not the magnitude of the
ance to central posteroanterior pressures to L 5 and
r eveal ed
p ressure change . She was also instructed to spen d
provocation o f the coccy x pain with sustained pres
time in supine lyin g practising controlled relaxed
sure to L4 .
breathing
Reassessme nt of her ability to isolate the contrac
with
bi -basal
expansion
and
rela xed
expiration.
tion of TA ind i c a ted there was no improvement of her
Passive treatment involved application of the L4-L5
capabil i ty to reduce the pressure wit h the inflated
lateral flexion PPIVMs to the right at g rade III and
pressure cuff under her abdomen in prone lying. I n
three repetitions of sustained ( 1 5 seconds) postero
addition. th ere w a s n o redu ction i n the overactivity of
anterior pressure to L4. Reassessment of l ate ral pelvic
OE. Assessment of the lumba r multifidus indicated
gli ding indicated
there was no change in her abil i ty to perform a con
movement to the left . but with no maintenance of
traction of this muscle.
a
slight i ncrease in pain during
pain on return to the neutra l position. Muscle con
Skye stated that she had practised the exercise at
trol was also re tested a fter the application of the
home bu t had fo u n d it very difficult as she fel t that she
m a nual techniques
was doing ' n othin g ' . In response to this she had con
was any change i n task performance as a result
tracted the muscles with increased effort so that she
of the intervention . If manual techniques change
was aware of the contraction. Although she was able
muscle activi ty or neurophysiological mechanisms ,
to
determi n e
whether
there
to feel that this resulted in the inappropriate contrac
it may be possible to change control. although this
tion of OK s he fe l t that it would be better for her
has not been tested experim e n ta l l y. S kye exhibited
because it would be m a k ing the muscles stronger.
no change in perform ance follovving the manual
Skye was educated that the exercise was aimed at
intervention .
retraining the coordination of the tru nk muscles and
Skye was given adv ice on the use of a rolled towel
not at m aking the muscles stronger. She was further
for lumbar support in order to determine whether this
educated in the importance of precision in her train
would assist her pain control during periods of sus
ing and that practising an exercise that was not cor
tained sitting. She was also giv e n general back care
rect would n o t imp rove the coordination of these
and lifti ng advice and adv ised to retu r n in 1 week .
Copyrighted Material
CLINICAL REASONING I N ACTION: CASE ST UDIES FROM EXP ERT MANUAL T H E RAP I S T S
� IJ � D
R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R E AS O N I N G C O M M E N TA RY
Yo u appear to have s p e n t c o n s i d erable ti m e i n
was temporary. However, the improvement of her
e d u cati ng t h e pati e n t as part o f t h e manage m e n t
symptoms was only maintained for
of the p ro b l e m . D i d y o u specifi c a l l y a s s e s s h e r
suggesting t hat t he bene fi t fro m the passive manual
a
limited period .
u n d e rsta n d i ng o f t h e p rob l e m p r i o r t o p rov i d i ng
techniques was short term . This resiJonse did not i ncU
these exp lanati o n s ? C o u l d you a l s o c o m m e n t on
cate that the exercise approach was u n likely to be
t h e i m p o rta n c e of e d u cati o n i n yo u r ove ra l l
beneficial , as any effect from exercise would not occ ur un t i l t h ere was a c h ange in muscle fu nction . Because
m a n age m e n t.
there had been no c h a n ge i n the deeiJ muscle function
• C l i n i c i an 's an swer
since the first treatment, because of incor rect per
Skye was questioned directly ab out her understand ing o f her problem a nd infor m a l l y throug h conver sation . From the assessment. it was clear t h a t her u nderstanding of the problem was limited . She had previously been in formed of a simple cau se-effect rel ationship between a single tangible pathol ogy and her pain . Follow ing fail u re of the su rgery to remedy her symptoms she was not provided with any fu rther expl a natio n As we were about to take on .
a
largely
self-motivated prog ramme of exercises. it was criti c a l for S kye to understand completely t h e theoretical c o n s tru ct upon wh ich this approach to management was based . Ed ucation was also needed to ensure that the exercises were performed optimally. For instance, the initial exercise that Skye was to perform does not conform to the expectation that many patients share (Le. exercise is aimed at incre a s i n g m u s cle strength ) .
formance of the exercise. it was not eX iJecled that the muscular s u pport for the spine wou l d be improved and able to control the symptoms . Therefore. the effect of the first t reatment was con sistent wit h the initial biomec h a nical h y po thes i s in t h a t the selected manual techniq ues had resulted in improvement of symptoms. al thoug h d e l a yed
clinical change in symptoms was not inconsistent with the approach as Skye had n o t yet successfu lly trained the system and her exercise needed re tlne men t. On this b a s i s it was decided to continue with the manual techniques and to persist striv ing for independent activation of TA.
II
What th oughts d i d you have at assessing the i n i tial treatm e n t rega rd ing her p rogn o s i s for maste r i ng an a u tomatic motor p rogra m m e of
Therefore, it was necessary to change this perception by helping Skye to understand t h e reasoning behind the performance of gentle precise co ntr a ction s
.
In
add ition . it was i mportant to ed ucate S kye about treatmen t ef ficacy ( Hides et aI . , 1 9 9 7 : Jnil et at . , 1 9 9 8 : O ' S u llivan e t aI . , 1 9 9 7) and realistic expect ations in order to encourage mot iv ation. Edu cation is clearly one of the main factors when embarking on a management prog ramme that is pri m a rily dependent
.
Fur thermore, the fail ure of t h e exercise to make a
i m p roved muscle contro l , given the d i fficu lties s h e was ex p e r i e n c i ng? Did you find it necessary to adapt or try d i ffe rent teach i ng strategi es i n res p onse t o t h e pati ent's ab i l i ty, u n dersta n d i ng a n d l earn i ng sty l e ?
• C li n i cian's an swer Foll owin g t he first experience. it became clear that it
o n s e l f- m a n a gement and independent exercise.
would be difficult to ac hieve the correct contraction
D
made to persist try ing for the ideal response. However.
H ow d i d you i n terpret the res ponse to the fi rst treatm ent?
of t h e deep muscles . Collabora tive ly, a decision was
i t was important to keep in mind the need to review the situation after several treatments to determine whether Skye was progressing with this demanding
• C l i n i c ian's an swe r
cogn itive approach. It was also critical that Skye did
The conclusions drawn from the initial response were
not become frustrated with the time requ ired for her
that there was a delayed ( 3 0 minute) response to the
to make a chan ge. The difficu lty in achieving the
manual techniques and that the slight increase in pain
cor rect contraction arose because, first. S kye req ui red
resu lting from the performance of these techniques
cop io us feedback and intense concen tration to be
Copyrighted Material
7 C H RO N I C LOW BAC K A N D C O C C Y G EAL PAI N
successful a n d . second ly. she continued to bel ieve tha t s t r e n g t h was importa n t. Beca use o f t h is . i t was neces sary to ta ke t h in gs s l ow l y a n d r eg u la r ly re i n force the main points regard i n g effo r t and p r ec isio n . It was also necessary to be more expl icit abo u t the treatment go a ls and manage m e n t approach . As she had poor movement p e rce pt i o n . i t was e ss e ntial t o a dapt the s trategy to prov i de a l ter native sou rces o f fee d b a ck ( i . e . p r e ss u re c h a n ge s using the pres s u re c u ff u n d e r t he abdomen ) to enha nce he r awa reness of t he con tr a cti on Conseq u e n t ly. there was n o ch a n ge in teach .
i n g stra tegy. just rei n forcement of the exerc ise a n d
the
Llse of a l ter n a tive strategies to p rovide feedback.
• C l i n ical
th e r api s t and patient. al ong with ex p l anat i o n and re ass u ra nce
.
Patie n t lear ning is a
crucial fact or
in the success of a ny treatment outcome. but par ticul a rly when it invo l ves self-man agement. The cl i n ic i an in this case h a s obvio usly learnt that. in c hr on i c presentations such as this where the patien t ' s own meaning perspectives. including fee l
ings (e.g. helplessness ) . b el ie fs (e.g. muscles o n ly req uire strengthening) and understandings (e.g. the coccyx is the p ro b lem ) are dysfunctional l impaired . .
it is often fruitless. if no t coun terproductive. to pur sue a course of treatment without addressing thes e issues th rough p a ti e n t education. Manual thera
reason i n g c o m m e n tary
pists need to develop their te ac h i n g skills continu ally. as they would their manual sk i l l s
Manual therapists must
be good teachers. To promote cha nge s u c c e s s fu lly in a patien t s behav iour. and consequen tly i n t h eir p ro bl e m . requ ires a
e mplo y these skills in cultivating
'
• T h i rd treatment ( 1
collaborative ap pr oa c h t o clinical r eas on i ng between
a
.
and to
collaborative
approach to th e ir p a t ien ts clinical pro b l e m s . '
week l ate r)
Her home programme of exercises i nvolved con
On r e a s sess m e nt. S kye again indicated that her pain
tinuation of her TA tra i n i n g . with the addition of
had been imp r oved for several d ays a fter tre atment b u t
active h a ms t ri n g stre tc hes (i n s upin e lyi n g with her
had re tu r ned. There w a s little cha n ge i n active move
hips be n t t o 90 de g r e es ) . Gl u teal exercises ( bridging)
ment or passive j o i n t movement s i g n s However evalu
. were a l s o superimposed o n her attem p ted TA set t i n g .
.
ation of her ability to perform a n isolated contraction of
which at this stage was sti ll o n ly fair. The b ri d g i n g
TA t h is time i ndica t ed sl ight im prove me n t . Al tho u g h
exercise w a s a i med at improving the activation of the
she was u nable to r ed u ce the p ress ure in the cuff p l aced
gluteal muscles and was per fo r med [rom crook l y i n g
under her abdome n . she was able to perfor m the con
usi n g h i p extensio n . Prior to this bridging movement,
trac tion wit h less overactivity of OE . She still req u ired
Skye was i n str u c te d to pre-contract her TA .
encouragement to red uce the amount of effort she w a s
Postura l cor rection exercises we r e also commenced
using to pr od u ce the c o n tr a ctio n a nd performed better
at this tre a tmen t sessio n . T his i nvolved correction of
witho u t feedback from the pressure di a l In vie w of
her entire sp i n a l posture. Skye's natural attempts to s i t
this. she was a d v i sed not to use t he pressu re biofeed
or stand stra ight were associa ted with extension at th e
.
ba c k unit fo r tra ining and was i n s tructed in stead
thoracolu m b ar j unction rather than control of the
to u s e a mi r ro r to mon i t o r the movement of her
normal spinal curves. Postural co r rec tio n was com
abdomen fr o m the side. At t h i s stage, she was still not
menced
able to commence b re a th i n g while h old i n g a con t r a c
lumbar lordosis actively by ge n tly tilti n g her pelvis for
tion of TA , a n d so she was encouraged to i n crease
ward . To ass ist her to c o ntr o l the e xt e ns i o n at the tho
in s i t ti n g , where she was taught to control her
the number of repetitions to five. Passive treatmen t
racolumb ar j unction , she was told to hold her thumb
involved reappli cation of t h e j O int mobilizations used
o n her stern u m and li ttle fi n ger in her navel. and to
i n the last treatment with i n creased vigour a nd dura
keep the d i s tan ce between th e se two pOi nts stable as
tion , a nd the addition of transverse mobilizations of
s h e moved. Cervical spine posture was corrected by
L4 to the left at gr a de III. As the use of the rolled towel
te l l i n g her to imagine a s tri n g p u lle d up fr o m the ba ck
h ad been fo u n d to be benefi c i a l . Skye w a s advised to
of the top of her head . Skye was encouraged to adopt
purchase a l u mb a r support for use in the
this posture at wo rk each time she h e ar d the school
meeti n gs and at the c i n ema .
car, d u r i n g
bell for classes to finish.
Copyrighted Material
CLIN I C AL REASONING I N ACTION : CASE STUDIES FROM EXP E RT MAN UAL T HERAP I STS
•
� I } -
R E A S O N I N G D I S C U S S I O N A N D C L I N I C A L R E AS O N I N G C O M M E N TA RY
Why do yo u th i n k that the u s e of the pres s u re b i ofeed b a c k u n it was of n o val u e , if not cou nte r p ro d u ctive ? H ow d o e s its u s e d iffe r fro m t h a t o f the m i rro r ?
It was considered necessary not only to tra in the deep mu scle function b u t also to restore normal fu nction of all of the mu scles i n the l u mbopelvic reg i o n . This is critical because norma l fu nction o f these musc les
• C l i n i c ian's an swe r Altho ugh the pressure c u ff was used to provi d e add itional feedback a s to the success of the contra ctio n , i t unfo r t u n a tely mea nt that Skye focussed o n chang ing the pressure rather than the co ntracti on o f her abd o m i n a l muscles. The pressure i n the cu f[ can be reduced by several mech a n isms in addition to c o n traction o f TA , such as elevation of the lower ribs a n d l1exion
• C l i n i c i an's an swe r
at t h e thoraco l umbar j u nctio n . W h e n a
reduction in press ure occ urs without a ny motion of the rib c age o r pelv i s , i t is considered to be largely a res u l t of TA contraction ( R ic hard son et a I . , 1 9 9 9 ) . However, when motion o f the rib cage o r pelvis is produced , other muscles are then i nvolved ( e . g . OE) . F a i l u re to i nstruct the patient about these o ther pos sible mechanisms for decreasing pressure (or fai lure to iden tify them) may result in pra ctise o f a n i n appro priate contra c tio n . A l t h o ugh Skye was i n s t r ucted to keep the rib cage in contact w i th t he bed, s he had fo u n d this difficult to perceive. A s a res ult, Skye had learnt mec h a n isms to reduce the pressure t h a t were not asso c i a ted with TA contractio n , no tably Ilex ion of the thoracolumbar j unction and elevation o f the rib cage by contraction o f OE. Con sequently, the pressure b i o feedback technique had encouraged a n undesir able contraction and had fai l e d to provide i mproved kinesthetic awareness of the con traction . By compari son, the mirror provided more usefu l feedback that e n abled Skye to focus o n the correct performance o f t h e contraction ( i . e . lower abdominal move ment) and to detect in appropriate strategies (e.g. rib cage depres sio n , obser vable contraction of OE, movement pre
is essential to optimize the con trol of the s p i n e , as all i u mbopei vic muscles contri b u te to speci fic aspects o f stability. I n Skye 's case, the red uction in length of the h a mstring muscles acted to l imit hip motion and res u l ted i n an i ncreased demand for motion at the lumbar spine. This wo uld occ u r partic u l ar ly at the level where there was a tra nsition between the regions of h i g h and low mob ility ( i . e .
1 3 -L4 ) . By
i n creasing the length of the hamstring m uscles , the a i m was to m i n i mize fu r ther the l o a d / s tress on the lumbar spine and increase the contr i b u tion of the hip to lumbope lvic motio n . Correspon d i n gly, i t w a s consid ered desirable t o restore n o r m a l gl u teal activation to assist with the control of l u m bopelvic motio n .
Althou gh the deep muscles a re able to
control segmen tal stab i l i ty, they h ave only a l i m i ted ability to con trol the ove r a l l orientation o f the l u mbar spine and pelvis. There fore, the exercises for the hip mu scles were not expected to h ave a d i rect effect o n the control o f the d e e p tr unk m u sc les, but they were expected instead to reduce the rel iance o n l u m b a r motio n . Many therap i s ts c o n s i d e r postu ra l co rrecti on to be an al most obl igato ry part of the managem ent of the pati ent with l ow back pain. What was yo u r reaso n i ng b e h i n d t h e d e c i s i o n to i n trod uce these exe rci s e s fo r co rrecti ng S kye's postu re ? I s there ' any re search ev i d e n c e to s u pport th is approach ?
• C l i n i cian's an swe r
dominantly of the upper abdomen , a n d fa st o r j erky
Postural correction has u nderpin ned many clinical
contractio n ) . Therefore,
a pproaches . The decision to i nclude postur a l co rrec
unlike
the pressure c u fr.
observation with the mirror provided feedback of
tion as a compo nent of Skye ' s management was based
correct and incorrect performance, and so the desired
on a number of factors. First. there are relatively con
movement (change in abdominal co ntour) could not
sistent d a ta to argue that the loading through the spine
be simu l a ted by imprecise con tracti o n .
is more optlmal in a ' neutra l ' position with lu mbar lor dosis and thoracic kyphosis (e.g. McG i ll and Norman ,
What was yo u r rea s o n i ng fo r p re s c r i b i ng
1 9 9 3 ) . Early data also indi cate that posture affects
hamstring a n d g l u teal exe rc i s e s ?
factors such as disc pressure (Nachemson and Morris,
Copyrighted Material
7 C H RON IC LOW BAC K AND COCCY GEAL PAIN
1 9 (4 ) .
Second ly. it is s u ggested c l in ically that activity
of the s u perfici Cl I m usc l es may be affecte d by posture
• C l i n i cal
reasoni ng commentary
(or may a ffect postu re) . For example. overactiv i ty of OE
Resea rch-b ased e vide n ce , whether i t be empirica l
in associ a t i on w i th
proo f or bio logic a l bases a s discu ssed in this
a
de pressed rib cage an d activity of
thoracic e rector spinae musc les appears c l i n ica l ly to
response, can be used to
favou r a m i l it a ry type posture ra ther than the normal
mak i n g process rel a ted t o the management o f
inform the
decision
neutral curves . T here is ev idence that these muscles
indiv i d u a l patients. What is crucia l . t h o u g h , is t o
a re ovefCIct ive i n m a ny people with low back pain
determine
(Radebold et
a I ..
2()()( )). Therefore. correction o f posture
may assist in t h e re-ed ucation of normal coordination o r the t ru n k m u s c l e s .
c l i n ic a lly
i f t h e ev i d e nce is
a ppropri a te
a n d applic a ble for a particular p a tie nt . m a t u re organ ism
( di s c u ss ed
model
i mpl ies . n o two people will have
As the 1)
in Ch.
ex a c t ly
the same
O n e i s s u e t o c o n s i d e r i s t h a t it i s n o t normal t o
presentation give n their u nique pa st experiences
a d o p t a n e u tra l pos i t i o n a n d st ay there. A l t h o u g h th is
and curr e n t con texts . Clinical reaso n i n g must be
m ay be o p t i m a l fo r t asks that i nvolve s u s t a i n ed load
appl i e d to resea rch-based evidence to establish the
i n g . i t is abno rm a l to m a i n tain
simil arity of the patient ' s presentation to that
a
ne u tra l spi n a l pos
Lu re r i g i dly w i t h o u t va ri a t i on . It is known that the
stud ied and to administer
centr a l nervous system u ses move ment to assist
pri ately considering the u n iq u e features of the
i n the absorption of fo rces (Hodges et al . .
1999).
the
presentation. The effects o f
i n terven tion appro
the
research-based
Therefore . normal fu nction shou ld encourage a func
i n terven tion for a n individual patie n t sho u l d also
tio n a l range of movement. w i th specific i ns t r uctio n
be su bj ect to the same clinical e va l u a tion ( o r
for s i t u a tions when i d e a l posture may be requ ired, b u t
reassessment)
with a n u ndersta n d i ng o f a llowi n g t h e s p i n e to move.
i n terven tio n .
S kye 's
re tu r n
2
weeks
later,
she
r e p o r ted
decreased pain fo l lowin g the previous tre atment, w h ich was m a i nt a i ned for a l o n ger period ( a pproxi ma tely 4 days ) , w i th a g radual return o f her symp toms over this time. She stated that t h e performance of the abdomi n a l m u scle exerc ises gave h er a subj ect
ive feel in g o f increased con trol of her spin e. She could delay the onset of p a i n duri n g period s o f prolo n ged sitting and standing by perform i n g regu l ar TA con traction s . This had been p a r ticu larly benefici al d u r i n g s ta ff meetings a n d while attend i n g the cinema . On physical exami na tion , there was slight reduction o r lumbar pain on la teral pelviC gl i d i ng to the ri ght and decreased coccyx p a i n w i t h sustained postero an ter i or press u re to L4 . Reassessme n t of her ab il i ty to contrac t TA i n d i c a ted that she was still u n able to red uce the pressure with the pressure cuff placed u nder her abdome n , but she was now able to perform the contraction e a si ly without instruction o r feed back . Pa l p a ti on of mu l t i fid us d u r i n g performance of the pel vic rioor/TA contraction i ndicated a p a lpable bilateral contrac t i o n that was greater on the left than
th e right a nd whi c h was able to be performed in slow a n d controlled manner.
as
an
experie nce-based
Progress i o n i nvo lved teac h i n g Skye to perform the
• Fou rth treatment (2 weeks later) On
process
a
contraction i n the more func tional positio n o f s u p por ted stan din g and the incorpora t i o n o f breathi n g w ith t h e contraction. Breath i n g tra i ni n g i nvo lved perfor m a n ce or a contraction of TA and t h en add i n g s p e e c h (cou nting) to encourage contro lled a irflow. I t was necessary t o t a k e t h i s i n t erme d i a t e s tep before commen c i n g true b r e a t h i n g tra i n i n g because of her d i fficulty with this task. After practice holdi n g the TA co n tra cti o n w i t h s pe ak i ng , Skye was encou raged to commence bi- b asa l d iaphragmatic brea t h i n g super i mposed on the TA contrac tion . To assist with this integratio n , S kye was advised to p lace one hand over the l ower rib c age to give feedback o f b a s a l rib c a ge expa n sion and the other h a n d over TA i n ferior to the ASIS . She was instructed to breathe with bi-b a s a l expansion and abdom i n a l w a l l move m e n t w i th e a c h breath, rather th a n the sha llow u pper c h e s t brea th i n g t hat patients o ften perform in c o nj u nction w i t h t h e d e e p abdom i n a l muscle contracti o n . In terms of pro g ression of the exercise i n to fu nc tional positions, S kye could most effectively pe rform the c o n traction o f TA if s he stood with h e r fee t approx i m a tely 2 0 c m from t h e wall wi th h e r p e l v i S resti n g a g a i n s t t he wall. She w a s enco uraged t o do t h i s exercise thro u g h o u t th e day between c l a sses and
Copyrighted Material
CLINICAL REASONING I N ACT I O N : CASE STU D IES FRO M EXPE RT MAN UAL THE RAPISTS
to continue her training in prone ly i n g using visual feedback from the mirror. Eva luation of the postural correction exercise i ndicated that she still required a great deal of concentration to ach ieve the desired position and was finding this d i fficu lt to accompl ish at work. Passive j oint movement techn iques were reap plied with progression or duration or the sustai ned pos teroanterior pressure to L4 and performance of the L4-L S l ateral fl e xio n PPIVM at grade IV Transverse mobilization was repeated at the same g rade but in an increasing degree or lateral flexion of the trunk to the right to move rur ther into the range or motion. In view of the improvement in her symptoms, but considering the slow rate of change i n Skye' s abi lity to perrorm a contraction of TA , she was given 1 month to practise the exercises independen tly. She was i nstructed to increase the number and duration or the contractions according to what she was able to manage. She was also instructed to use palpation and observation of the activ ity of OE as a gUide to this progression.
Bii'i1'i§i." I&B9" i§.i_ Over the next 6 months, Skye was seen initially monthly ( ror 2 months) and then every second month. The main limitation to her progress was the slow rate of change in her trunk muscle fu nction. She required long periods between treatmen ts in order to be able to detect a change in her abil ity to perform the contrac tion errectively. Deep m u s c l e con tro l
After t h e fir s t month, Skye h a d mastered the ability to perform a contraction or TA independently from the superficial abdominal muscles. Additional exercises were included to improve activation of the lu mbar multiftdus. For the first exercise, Skye palpated her multifidus in Sitting and performed gentle isometric contractions in combination with TA . She required spe cific instruction as to the correct hand placement and feeling for the appropriate contraction. Correction of the preciSion or the exercise was required at several ses sions berore the exercise could be perrormed optimally. Skye was a lso taught to perform a co-contraction of these two muscle groups during more functional tasks such as wailctng. She was encouraged to palpate the muscles initially in order to determine whether they were active and then to superimpose stepping.
I n c orporation of deep and su perficial m u scles
During this 6-month period, Skye prog ressed to the stage where she could perform a contraction or TA and reduce the pressure in the cufr placed under the abdomen by 4 mmHg. At this point, exercises to retra in the coord ination between TA and the superficial muscles were also commenced. These exercises started with her positioned in crook lyi n g with the i n ll ated pressure cuff under her lumbar spine. She was instructed to let her knee gently move out to the side without changing the pressu re i n the cuff, in an attempt to i ncrease rurther the load required ror spinal stabilization wh ile promoting dissociation with limb movement. This was gradu ally progressed to sliding one leg out stra i g h t and then l i rting her leg. Al l exercises wer e performed without letting the pressure change d uring the exercise. Other exercises included si ngle limb movemen ts a nd then con tra lateral arm and leg movements i n fou r-point kneel ing. and arm movements while sitting on a ball. For each or these exercises . Skye was instructed to contract her deep muscles prior to the addition or the load or the arms and legs. She was also encouraged to adopt a con trolled neutral spine position (using the method she had been taught prev iously) and to maintain this during the movements. Exerc ises were progressed after she was ab le to per form them accurate ly. For most exercises . she required some form of feedback. either from a pressure culT or mirror. to help to ensure that she kept her spine con trolled. Throughout this time, Skye continued to train her TA in prone ly ing. gradua lly increasing the holding time and the number or repetitions. She also continued to train the multifidus in standing with self-palpation of the co ntraction. The use of passive techniques made no rurther change to her symptoms and were, therefore. ceased. This allowed Skye to rocus on performing the active exercise regimen.
M ove m e n t pattern co rrecti o n
Addition a l exercises were i ncluded t o c h a n ge her moveme nt patter ns so a s to increase the movement o r h e r hips during tru nk movements without associated excessive movement at the thoracolumbar j u n ction. This i nvol ved exercises i n which she corrected the posture of her trunk ( as prev iously instr u c ted) and then flexed at the hips . keeping the position of the
Copyrighted Material
7 C H RON I C LOW BAC K AND COCCYG EAL PAI N
tr u n k stable w i t h combined contraction of TA and
ceased t h e TA exercises for 3 days t h e n her low b ack pain wou ld retu rn . It wo u l d then take 3 days o f exer
m u l ti fi d u s . W i t h eac h treatme n t sessio n , the d u ra t i o n o f t h e
cise for i t to again s u b s i d e . She had tested th is on at
red uction i n sym ptoms was increased, and over the
least two occasions to convince herself that there was
period of 6 months Skye described a g r a d u a l d ecrease
indeed a c a use-effect rel ationship between exercise
i n the overall level o f her sympto m s . S h e i mproved to
practice a n d the recu r rence o f p a i n . O n exa m in a t i o n ,
t he p O i n t where she experienced o n ly min imal pain
a l! active movements h a d full range o f m o t i o n , a n d
with prolonged periods o f sitting o r stand i n g , such as
pain c o u l d only b e reproduced slightly w i t h overpres
travel i n g in a p l ane for greater than 3 hours . She was
sure o f p e l v i c glid i ng to the right. Passive movement
adv ised to retu r n in 4 mo nths for rev iew.
exami n a t i o n fa Ued to provoke a ny coccygea l pain with sustained postero a nterior pressure to L4 . S kye was advised to conti n u e a d a i ly main ten a nce pro
F i n al p resentatio n
gramme each m o r n i n g that i n volved i n d ependent
O n h e r fi n a l presentation. S kye was rela tively pain
c o ntraction o f TA i n prone lying a n d m u l t i fi d u s i n
free. She was a b l e to perform her work d u ties with
sta n d i n g . S h e w a s a l so given a l i s t o f 1 0 exerc ises
m i nimal or n o p a i n a n d was n o l o n ge r l i mi ted i n her
( from those s h e had been practising) that i n volved
a b i li ty to sta nd for l e n g thy periods. However, s he
pre-con traction of TA a n d m ul tifid u s with the addi
continued to avo id sustained sitting a n d still used her
tion of slow controlled movements o f the leg o r arm .
l u mbar suppo rt when driving l o n g d i s ta nces or during
S h e w a s t o select two exercises fro m this list e a c h day
prolo nged meeti ngs . S kye comme n ted that if she
and vary them between days.
� j
-
o
REASONING DISCUSSION AND CL I NICAL R E ASONING COMM ENTA RY Cogn itive
How d i d you see the various d i ssociative
awareness
is
critical
in
facilita ti n g
exe rc i ses you used contributi ng to the
changes i n m o tor c o n trol in t h i s appro ach to m a n
ma nagement p rogramme ? H ow important was
agement. Although several other approaches to man
the patient's cog n i t i ve awa re n e s s in fac i l i tat i n g
a gement rely on restorati o n of fu ncti o n through
the se ch anges ?
a u tomatic facilitation of the c o r rect motor pa ttern ( for examp le, Janda.
• Cl i n i c i an 's
answer
1 9 7 8 ) , c o n temporary moto r
lear n i n g t h e o r y focusses strongly o n cognitive correc
The d i ssociative exercises were added to the manage ment programme to restore normal movement o f the l u mbopelvic region by reducin g the excessive motion of the lumbar spine a nd by increasing motion o f the hip. A t the initi a l assessment. i t was noted that most movemen t with trunk n exion occ u r red at the lum bar spine, with mini m a l contribution from the h ip . The fu nctional c h a racteristics of several of t he hip muscles (e.g. gluteus maximus and hamstrings) were consist ent with this observatio n . Although TA and m u lti fi dus should be able to enhance s pinal control throughout
tio n , with accurate feedback ab out movement per fo rmance and outcome ( Ca r r and Shephe r d , 1 9 8 7 ; Hodges, 2 0 0 3 ; Magi l l . 2 0 0 1 ) . As t h e motor coordina tion /ski l l improve s . the amount o f attenti o n /cogni tive awareness and
feedback that is req u i red
is
reduced . Once the ski l l is mastere d . then m a ny repeti tions are required i n order to tra in the response to become a u tomatic. There is pre l i m inary evidence that trai ning the trunk muscles i n this manner does result i n a change i n a u to matic activation in fu nc tional tasks (J u l t et a I . , 1 9 9 8 ) .
the range of motion, any attempt to reduce the re liance on spinal movement (as op posed to hip movement)
One of the problems of predom i n a ntly
was considered to be wor thwhile. A ny i mprovement
exe rcise based treatment regime n s can be
in this regard might assist i n mi ni mizing t h e stress o n
pat i e nt compl i a n c e . What strateg i e s do you
t h e j o i n t struct ures at t h e m id-l u m b a r level t h a t could
conside r were most useful in e n courag i n g
resu l t from excessive moveme n t .
compl i ance with thi s patient?
Copyrighted Material
CLINICAL REASON I NG IN ACTION: CASE STUDIES FROM EXPERT MANUAL T H ERAP ISTS
• C l i n i c ian's answe r
• C l i n ician's answe r
I bel i e ve that the str ate gy most useful [or encouraging
In Skye 's case, the reassessment of psychosocial issues
com pliance with Skye was education regarding the
was u n der taken by i n for m a l question i n g . I t w as c le a r
b as i s [or the exercise and the pote n t i a l benefit of the
from S kye ' s prog ress that she h a d accepte d t h e need
exercise programme. If a patient can understand what
to be re sp o ns i ble fo r her own recovery. The clinica l
the exercise aims to achieve and is prov i d ed with evi
process req uired a great deal of mo tivation and Sk y e
dence [or its efficacy, th e n motivation wil l be increased .
responded wel l to th i s c h a l l e n ge D u r i n g co nvers a
Another [actor of importance in this case was the rein
tion. attempts were co n t i n u a l ly m a de to re i n fo r ce the
.
[o r ce m e n t of the rela tive value of the passive and active
n o n t h reate n i n g natu re o f p a i n : t h a t the p a i n was no
components of the treatment. It was essenti a l for com
longer acting as
plianc8 that Skye took o n the o n u s o f res p o n s i bili ty for
Thro u g h q ues ti o n i n g it was obvio us th a t her a t t itude
her � provement. P atie n ts need to u nde rst an d th at
was c h a n g i n g . Her attitude t o her s y m ptoms became
th ey
m ore p os i tive
will be responsible [or a large part of the change ;
-
,
a
war n i n g of d a mage to str u c tures .
s h e ca t a s tr o p h i z e d less , and she no
the passive tech n iques may assist with sy mptom red uc
longer expected to e n d up i n a whee l c h a i r . W h i l e in
tio n , but the exercise component is essen tial for m ainte
some cases i t m ay be necessary to undertake more
'
'
nance. If a pa ti ent believes that th e pass ive tec hniques
formal meas ures ( e . g. ques t i o n n aires) , my
will mal<e them better regardless o[ wh at they do, then
S kye 's case was t h a t t he i n for m a l method was b es t as
the motivation to exercise may be red uced.
steady prog ress was observab l e ; to u ndertake more
bel ief i n
fo rmal ex a m i n a t i o n m ay h ave u n necessari l y empha Why does Skye appear to need regu l a r
sized the psychosocial i s s u e
.
exerc i s e i n order t o c o n tro l h e r sympto m s ? I s the retra i n i ng effect o n ly tempo rary?
• C l i n ician's
• C l i n i cal
answe r
Cliillcally, it appears that ma ny p a t ie n ts can cease to
exercise o nce the con trol of the deep muscles h a s b e e n restore d . I n clinical tri als t h e benefit of exercise has b ee n shown to be m a i n tained for 30 mo n t hs
( O ' S u l livan e t aI . , 1997). However, others such as Skye appear to need continued reinforcement of the contraction. This may be because of her poor general coord i n a t i o n or per h ap s an ongoing in h i b i tory process. The decision to encou rage Skye to continue wi th regu l a r exercise was o nl y determined from evalua tion of pr o gress and main tenance of response. althou g h so me initi a l fa ctors such as ' low tone' may h ave s uggested the need for this approach to management. In t h i s par tic u l ar case, the l i ke n in g of d aily bru s hi n g o[ teeth to prevent tooth decay to the training of the d ee p muscles to prevent the recurrence o[ p a i n helped to encourage
reaso n i n g com mentary
Satisfactory patie n t comp l i a nce w i t h an ongoing exerc ise progra mme is
for
a
a
fu ndamen t a l req u i rement
successful ou tcome in m a n u a l t herapy,
illustrated here. Poor
c o mpl i anc e
as
is
w i t h self-man
agement regimens leads to poor self-efficacy and event u a l ly to poor t reatment ou tcom e s . Sell� m a n agement n e c e ss i t a t e s t h e patient sharing responsi
bility [or t h e ir problem, wh ich
can
be
a
d i mcu l t step
for some p a ti e nts with impaired or u n h e lpfu l bel iefs and u n ders t a n d i ngs a b o u t their problem and i t s
treatmen t . particula rly i f they o n ly expect or w i s h to be a passive recipient of t h e ' hea l i n g h a n d s ' o f t h e manual therapist. T h e clinical reasoning of t h e
expert clinician i n t h i s case h a s again highl igh ted the cru c i a l role of e d u c a t in g the p a tien t , especia l ly about t h e proven or likely be nefits of
a
self�m a n a ge
men t prog ramme, in order to foster motiv ation and
acceptance of the need for ongoing m a i n te na n ce .
compliance, Effective skills i n comm u n ication and
1:1
the preventive ro l e o[ bru s h i n g one's tee t h ) , are a n
Ea r l i e r you noted that t h i s pati e n t h a d pote n t i a l psychosocial p ro b l e m s that you fe l t cou l d be con tri b u ti ng to h e r pain state, and yo u o u tl i n e d th ree meas u res y o u p l a n n ed t o u n d e r ta ke to a d d ress t h e m . C o u l d you c o m m e n t n ow on yo u r reas sessment of h e r psychos o c i a l status a n d wheth e r this was a p ro b l e m ?
t e a ching such as the u se of a s i m p l e ana logy ( i . e. ,
i mporta n t part of t h e armamentarium of t h e exper t manll a l therapist. It is evid ent in t h i s response that j u st a s p hy s
i c a l i m p a i rments h ave been reg u l a rly reassessed
( e . g . motor con trol ) , so too h ave psych osocia l
Copyrighted Material
7 CHRONIC LOW BACK AND COCCYGEAL PAIN
impairments However, t h e
( e. g . m a l adaptive beliefs about pain ) . reassessment o f psychosocial factors
i mproveme n t . Nar rative reason ing and commu nic ative
m a nagement
(e.g.
c l a ri fyi
,
therefore, appl ied i n teractively and coll abora tively
had
a
were,
to reve a l and act on the patient's m e a n i n g pcrspcc
previously identified that the
p a t ient may have had
counse l l i n g )
ng
ual)
manageme n t strategies appl ied for the same factors . The clinicia n
and
,
expla i n i n g ,
process and has been closely i ntertwined with
n e gotiating
li s ten i n g
has clearly been more of a n i n formal ( a lbeit contin
tives ( see Ch . 1 ) . C h a n ge
was
obviously
effected
by
t h i s communicative approach, and validation was
l a ck of i n s i g h t i n to the psy
chosocial factors i n ll u c n c i n g her problem, which
ach ieved through therapist-patient common u nder
could h ave potenti a l ly created o b s tacles to her
standing
and consensus .
• Refe rences A gos to n i .
E. a n d C a m p be l l . E . f. M . ( 1 9 70 ) .
T h e a b d o m i n a l m u s c l e s . [ n The
e x te n s ion e frorts. J o u r n a I o f Orth oped iC Researc h .
1 3 . 8 0 2 -8 0 8 .
eva l u a t i o n of transversus abdo m i n i s . Spin e. 2 1 . 2 6 40-2 6 5 0 .
N e u r a l Control ( E.f. M . C a m p be l l .
R.P. . M i l l a r. A .B . a n d S i l ver. I. R . ( 1 9 8 7) . An electro myo
E. Agosto n i a n d J.
graphic study of the abdominaJ mu scles
tra n s versus abdom i n i s i s n o t i n fl u
d u ri n g pos t u r a l and respi ratory
enced by the d irect i o n of arm m ove
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Arendt-N ielse n . L .. Graven- N ielse n . T. . Svarrer. H. a n d S ven sso n . I'. ( 1 9 9 fi ) . T h e i n fl u e n ce of low back p a i n o n m u sc l e a c t i v i ty a n d coordi n a t i o n d u r i n g ga i t : a c l i n i c a l a n d ex perimenta l
study. Pa i n . h4. 2 3 1 - 2 4 0 . Bogd u k . N. ( 1 9 9 7 ) . C l i n ic a l A n a to my o f t h e L u m b a r S p i n e . 2 nd ed n .
Motor Relearning P rogra m for S troke.
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m u scles around a neutra l s p i n e
22. 2 2 0 7-2 2 1 2 . Cresswe l l . A . G . . O d d s s o n . L . a n d postu re. S p i ne.
T h orstensso n. A . ( 1 9 9 4 ) . The i n fl u ence o f sudden pertu r b a t i o n s on t r u n k mascle a c t i v i ty a nd
G u rfi nkel . V S . . Kors .
Y. M . . PaJ ' tsev. E.!.
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Bra in
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1 1 4 . 3 02-3 70.
1'. . R i c h a rdso n . C . a n d Ju l l . G . t h e re l a ti o n s h i p between laboratory a nd c l i n ic a l tests of ( 1 9 9 6 ) . Eva l u a tion o f
pensation o f res p iratory d is t u r b a nces
lran sversus a bd o m i n i s fu nctio n .
o r the erect postu re o f man a s an
Physiotherapy Res a rch Inter n a tion a l .
a r t i c u l a r i n teracti o n .
[n Models o f the
Structural - F u n ct i o n a l Organization of Cer ta i n B i o l ogica l Systems (LM. Gel fa n d .
V.S. G u r fi n ke l . S.V Fom i n a n d
M . L . Tse tlin . cds . ) pp. 3 8 2-3 9 5 . C a m bridge.
M A : M fT Press.
1 . 3 0-4 0 . Hod ges.
P. V/ . B u tl er. I. E . . McKen zie. O. K .
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of P hysiology. 505. 5 3 9- 5 4 8 . P. W . G a n d e v i a . S . C . a n d Richardso n , C . A . ( l 9 9 7 b ) .
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( 1 9 9 7 ) . M u l t i fi d u s muscle recovery i s
Co n tracti o n s o f spec i fic abdom i n a l
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musc l es i n postu r a l tasks a re affected
a c u te . fLrs t-episode l o w back pa i n .
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Hodge s . P. W. . Cresswe l l . A . G . and
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Thorste n s so n . A. ( 1 9 9 9 ) . Preparatory
Lon d o n : Harcou r t.
Rese a r c h , 1 2 4 . 6 9 - 7 9 .
Phys i c a l Therapies
i n tra-abd o m i n a l pres s u re wh.i.le
Hodges . P. W a nd R ic h a rd s o n . C . A .
Hodges .
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D e Troyer.
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Go ldma n . J.M .. Lehr.
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P W. a n d Gandevia . S . c . ( 2 000a ) .
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P w. . Moseley. G . L . Gabrielsson . A .
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.
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H o d ges. P. W a nd G a nd e v i a . S . C . ( 2 0 0 0 b ) . Activation
o f the h u m a n d i a p h ragm
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d u ring a repeti tive postu ral task.
A bstracts 2 7 . Wash i n g to n .
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Hodges . E W a n d R ic h ardso n . C . A .
Hodges .
DC: Society
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D.
M . . Stokes. L A . a n d La i b l e . '. P. ( 1 9 9 5 ) . Ro l e of' m u sc l e s i n
( 1 9 9 6 ) . fnefnc i e n t m u s c u l a r stabil iza
a n d G a n d evia, S . C . ( 2 0 0 1 b ) . L u m b a r
t io n o f the l u m bar s p i n e a ss oc i a ted
spine s t i ffn ess i s i n creased by e l e v a t i o n
l u m b a r s p i n e sta b i l i ty i n m a x i m u m
with low back pa i n . A mo tor control
of i n tra-abdom i n a l pressu re.
G a rd n e r-Morse.
Copyrighted Material
CLI N I CAL REASON I NG IN ACT I O N : CASE STUDIES F ROM E X PE RT MAN UAL T H E RAPI STS
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xvnr o f the Soc iety
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A b i omecha n ic
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(M .D. Grab iner. ed . )
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and mo b i l i ty in po s t u ra l con tTol:
B iomec h a n ics
e v i d en c e rrom p o s t u r a l compensation
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H u m a n Kinetics.
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ror re s p ira tio n . Ex perim en t a l Bra i n
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to rib cage. A m er i c a n
Rev iew o r
Re s p i r a to r y Disease. 1 1 9 . 3 1-3 2 . Mose l ey.
G . L. a n d Hodges. P W. ( 2 0 0 1 ) .
Radebold.
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low back pa i n . Spine.
2 5 . 9 4 7-9 5 4 .
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Exe rc i se for S p i n a l Se gm e n t a l
Stab ilisation in Low
S c i e n t i fi c B a s i s a n d C l i n ic a l
Wa s h i n g to n . DC: SOciety for
cause d i ffere n t i a l effects on pos t u r a l a c t i v a t i o n o r the abd o m i n a l m u scles in h u m a n s . In 3 1 s t A n n u a l
Neu roscience. Soci ety ror Neuroscience
Meeting or t h e S o c i e t y for
Liv i ngstone.
Abs tra c ts on l i ne .
N e u roscience. Sa n D i e go . CA. A b s tr ac ts 2 7 . Wa s h i n gton. DC: S o c i e ty
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ror N e u roscien' c e A b s t r acts .
Nachems o n .
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Back Pa i n :
Edi n b u rg h : C h u r c hi l l
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back pa i n . Spi n e . 1 4 .
9 9 2-100 1 .
M e c h a n i sms i n M a n i p u l ative Th erapy
I n tra v i ta l dyn a m ic pressure
( I . M. Korr. ed . ) pp. 2 7-4 1 . Lo n d o n :
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( 1 9 9 7 ) . P u l m on a ry respon ses d u r i n g
P l e n u m Press.
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( S upp I . ) . 1 -4 0 .
Jull.
T h ird Interd isci p l i n ary World C o n g ress on Low Back and Pe l v i c
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and exercises.
Re h a b i l i ta t ion
O. P. . H i m a n i . A . a n d Sing i l . S .
P hy si o l o gy a n d 4 1 . 1 6-2 2 . We i s e n berg. M . . Raz. T a n d [·fener. T. J ou r n a l or
Pha r m a co logy.
M edi c i n e 1
( 1 9 9 8 ) . The i n n uence of 11 1 m - i n d u c ed
N a c h e m so n . A . a n d Morris. J . lvl . ( 1 9 6 4 ) .
I n v ivo m e a s ure men t or
Ta n d o n .
i ntradisca l
p r e s su re : discometry. a m e th od ror the
i n the lower l u m b a r d i scs . j o u r na l or Bone and joint S u rgery. 4 6 A . 1 0 7 7- 1 09 2 . O · S u U i v a n . P. B . . Twom ey. L.T. a n d AJlison. G.T. ( 1 9 9 7 ) . Ev a l ua t io n o r spe de termi n a t i o n or presu re
mood on pain perce ption . Pa i n . 7 6 .
3 6 5-3 7 5 . W i l ke . H . j . . Wolf.
S . . Claes. L . E . e t a i . o f the
( 1 9 9 5 ) . Stab i l ity i n c rea s e
l u m b a r spine w i t h d i fTerent m u s cl e g ro u ps . A biomec h a nica l in v i tro s tu d y. S p i ne. 2 0 . 1 9 2 - ] 9 8 .
4 2 1 -4 3 0 .
cific s ta b i l izi n g exe rcise in the treat
D . ( 1 9 8 9 ) . T he Pe lvic Girdle: A n A p pro ac h to the E xa mi na t i o n o f the
m e n ! of ch r o n i c low back pain w i th
Howland. E . W . N i c hol s . S.N. ( 1 9 9 1 ) . The erre c ts of i n d u ced mood on l a bora t o r y p a i n .
r a d i o l o g ic d i agnosis of spon dylolysis or
Pa in . 4 6 . 1 0 5 - 1 1 1 .
Lee.
Copyrighted Material
Ze l m a n . D.C . .
a n d Cleeland . C.S.
Ankle sprain in a 14-year-old girl Gary Hunt
�
SUBJECTIVE EXAMINATION
Tiffa ny is
a
14-year-old fe male high scho o l fres hman
who has been referred with
a dia gnosis of right
He ordered r adiogra phs o f the foot and ankle to rule out any fracture, dislocation or epi physeal abno rma l
lateral an kle sprain. She presents as an inte l l i ge nt.
ity. Posteroante rior, l atera l and ankle mortice views
energetic youn g l a d y who has been very s uccessfu l
were t a ken and read as norma l . She was i nstructed by
in school. both scholastical ly and in extracur ricula r
the su rgeon to use the crutches with a non-weig ht
act ivities. She atte n d ed her ll[st therapy sessi o n with
bea ring gait and to perform a nkle d orsiOexion and
her mother. who was very supportive and appro
plantarl1exion
priately concer ned about her da u g hter's l a ck of
Tiffany was not improving and 2 weeks l ater repeat
exercises
within
pain
tolerance.
radiographs were ord ered to see if a ny bony c h anges
improvement from a sprai ned ankle. Tiffany ori ginally inj ured her right anlde approxi
had occurred that mig ht have s uggested
a
he a ling
m a te ly 3 to 4 weeks prior to this appointment. The
stress fracture. This second set also read as n orma l .
injury occurred while she was participating in
T h e su rgeon then decid ed t o refer Tif fa ny for my e v a l u
a
practice session for her cheerleading/tumbling squad.
ati on and m a n a gement.
Tiffany described the mechanism of injury as an i nver sion anlde sprain when she landed on another team member's foot during a li f t manoeuvre. She rested for a
History
few moments. and a lthough the anlde was tender. she
Tiffany
was able to continue the work-out session. Three days
crutches and non-weight be aring on the right leg. S he
later she returned to the gym for a follow-up work-out
was very reluctant to place the foot o n the 110or. She
and reinjured
ambulated into the clinic
using ax illa ry
the s ame ankle following a jwup man
had not been able to wear a shoe to this point bec ause
oeuvre. She landed on the outside aspect of her foot
of slight anlde and foot s we l l i n g, and bec ause of
and described hearing a 'pop', inunediately experienced
incre ased sensitivity, primarily over all her toes a n d the
severe pain and was u n able to place any weight on the
antero latera l aspect of the foo t and ankle. Tiffany was
right foot. Her coach referred her to an athletic trainer
only able to tolerate a n elastic band a ge a nd a n over
fo llOwing the second injury. The athletic trainer saw her
sized l1eece stocking for anlde su pport and protection.
the sa me day and advised that she apply ice. elevation
She rated her pain as 0110 at rest. but with any weight
and a compression \vrap, and exercise the foot as much
bearing or pressure the pain became very intense a n d
as possib le. He a lso encouraged her to wal l < with axillary
throbbing j u s t inferior to the lateral m alleolus, with a
crutches while bearing as much weight as tolerable.
tingling p a i n located over the a n terola tera l aspect of
FollOWing 2 d ays of this approach a n d no improve ment Tiffany was evaluated by an orthopaedic surgeon.
the ankle (Fi g.
.
S.l). Upon further discussion, Tiffany
stated th at the foot would become a dark purple colour
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123
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
Throbbing pain
Fig. 8.1
Reported areas of symptoms.
and spot ted when it was in the gravity-dependent pos ition f or even a few seconds. The throbbing and tin gling in the foot and ankle also intensified when the foot was pl a ced in the d epen dent position for 1-2 min utes. She also related that her toes and forefoot would begin to shake sometimes. but that it would n o t l as t
� IJ D
for more than a few seconds . This appeared to occur mostly when she tried to move or position her toes or ankle. She often noted that her right toes and ankle were c ooler than on the opposite s id e . Her physician had advised her to begin a nti inflanunatory medication (naproxen 375 m g twice daily). which she took sporadica lly. T iffany used the medication for the first 2 weeks after the second injury and then d isconti nued it. but she was unsure whether the medication had been of any benefit. She also applied extra moisturizing lotion on her forefoot daily to overcome dryness (Fig. S.l) and maintain normal skin tex tur e . Tiffany said she had no previous history of ankle injuries or any history of spinal complaints. She hac! no present symptoms/problems elsewhere and her gen eral health was unremarkable . Her goal is to return to her cheerleading squad as soon as possible and to par tiCip ate in a cheerl ead ing competition Ln 2 weeks.
REASONING DIS CUSSION AND CLINI CAL REASONING COMMENTARY
What were your th oughts regarding the mechanism of the second injury and factors contributing to the injury?
• Clinician's answer Tiffany was not exactly sure. but she thought th at
the ankle tu r ned ove r lateral ly after a jump man oeuvre. By her description . I felt that she had prob ab ly sustained an i nversi on ankle sprain that involved all of th e lateral soft tissue structur e s . The i n it ial injury may have compromised her proprioceptive c apabi l ities and/or modi fied her motor pattern sec ondary to low-grade nocicep t ive pain mechanisms. Furthermore, the activity of tumbling can be unpre dictable concerning l a ndings. The second injury
could have occurred because the tissues were still inflamed with slight nocice p tive pain present from the init ia l injury. What were your working hypotheses at this stage about the possible sources for Tiffany's symptoms and disability? What findings so far supported an d negated these hypotheses?
• Clinician's answer My working hypothesis at this time was that T i ffa ny had co m plex regional pain sy ndro me type II (causalgic-type pain p atte r n ) with peroneal ner ve involvement (Harden et at.. 2001: Janig and Stanton Hicks, 1996). She displayed ne u ral imp air men t with vascular instab i l i ty. Primary hyperalgesia from injured tissue in the ankle region, and possibly sec ondary hyperalgesia from adjacent uninj ured tissue Uanig and Stanton-Hicks, 1996), char a cteriz ed her pain. The trauma seemed to involve the peron ea l n erv e p rod uci ng an abn orm al state of afferent impulses (sympathetic fibres) leading to abnormal regulation of blood now (changes in colour and tem perature ) and sweating (dr y ness) . Distorted infor mation processing in the spinal cord ap pe ar ed to be possible as indicated by the ab n or mal muscle resp onse in the toes (toes sh a k in g) . Neurogenic inflammation was also considered, as were capsular trauma a nd talar dome fracture. The plain radio graphs eliminated any epip hyseal injury. but more sophisticated imaging would be required to r ul e out osteochondral injury co mp l etely. However, because of the lack of functional return and the perSistence of
Copyrighted Material
IR)
8 A N K L E S P RAIN IN A 1 4 -YEAR-O L D G I R L
pain, unu s ual for a sprain ed ankl e which t y pi c a ll y heals more quickly, I co nsid e r ed neurovascular injury the dominant d i a g no stic component of her
clinic al
presen tation.
in se veral c ategorie s : • phy sical impairments and associated structure/ tiss ue sources (e.g. lateral soft tissue struct.ures) • pathobiological mechanisms. related to both
I)
What were your aims in taking this patient's
tissue healing (e.g.
history (subjective examination)? Did
n o c ic e p t ive)
inllammation) and pain (e.g.
• factors contributing to the injury (e.g. compro-
you actively search for any psychosocial implications for the management of Tiffany's problem?
mised proprioceptive capabilities).
Early ge nerat ion of hy po theses.
as
in this
case.
to understand all the factors l e a d i n g to her current
to prior experience with similar clin ical presentations. Expert cl ini ci ans access their wel l- de velope d knowledge base to recognize famil iar in itial cues. whi c h together begin to form a clin ical pattern. P re vi o u s experience with such clinical
d i s ab il ity. It h el ped to di rect my cl ini c a l exam
pattern s or presentations wi ll help to guide the sub
largely relates
• Clinician's answer My p r im a r y aim in taking the history
state of
was to h elp me
ination. Secondary aims include d u nd e r s ta ndi ng the
sequent
mechanism of injury, the s tate of inllammation, and
newly
examination
and
management.
with
acquired cl i nical data used con tin ually to
the possible p a tho bi o l o gi c al mechanisms causing
test and to refine hy pothes e s. thus further enrich
pain and movement i mp a ir me nt. I did not
ac tively consider any psychosoc i al implications-she was a
in g the clinician's kno w led ge base.
very outgoing and ene rgetic individual. However. she
ously been further refined upon completion of the
was
very g o a l oriented and
why she
w
wa nted to understand as not g et ting bette r.
The p rimar y diagnostic hypothes is has obvi patient history. However, the clinician has recog
nized that
the c li n ical findings are not
entirely c on
sistent with the typical pattern or presentation for a
' s pra i ned ankle'. Atypical findings. notably the
• Clinical reasoning commentary
slow rate of recovery. have
The c linic ian ' s response in reg ard to m e c hanism indicates
that even at this early
stage of the patient
visit he was Simultaneously considering hypotheses
tEl
alerted him to the likeli with an unusual va ri
hood that he may be de ali n g
ation of the syndrom e. proVidi n g him with
a
valuable oppor tunity to learn more about this clin
ical variation (i'om his patient.
PHYSICAL EXAMINATION
Clinical inspection identi fied a coo ler right foot and
The foot beca me mott led when place d in
the g r a vity
w hic h e x tend ed up to the calf. The temp er ature was 2.0oP (1.1 0c) cooler on t h e ri gh t side, as meas ured by a biofeedback temperature t he rm ist o r ( the r mometer). The pl an tar and d ors al as pects of the l ateral part of the rig ht fo ot appe a red dryer than those of the left fo ot . Although she d e n ied any numb ness in her f'oot, Ti ffany had decre ased sensation to touch in the s uperfi c i a l pe r on e al nerve distribution. She was a ctually surprised to dis c ov er that, in fact.
ed ge of the examina tion table. Capillary nIling
she had less sensation in the nerve distribution.
level of discomfort. AU active movements o f the toes,
leg,
dep e nd ent pOSition. and then blanched when elevated for 20-30 seco nd s. No associated
c h a n ge
in pain was
n oted. although she described a t hrobbing sensation in the foo t and an kl e when the foot
was d an gl ed over the time of the distal rig ht great to e was pro lo n ged compared with the left s i de. Pos te rior tibial an d dor s alis pe d is puls es were pres ent and e qual bilaterally. Manual mus
cle s tre ngth testing was deferred because of T iffan y 's
Copyrighted Material
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
subtalar and anlde joints were guarded and incomplete
and longitudinal axes (Elftman. 1960; Manter, 1941)
as
did not produce any notable discomfort and the end
a
result of pain. Slight quivering of the toes was at
times noted during the initial examination.
feel was also normal. Hip and knee motion was unre markable. No spinal examination was undertaken on the first visit as Tiffany had no history of spinal
Movement
complaints.
Assisted active movements of the ankle were measured
Right straight leg raise (SLR) without preposition
in prone lying with the knee extended. Dorsi!lexion
ing the foot or ankle produced d iscomfort and tingling
range of motion of the left ankle was 8 degrees. but
in the right lateral ankle area at 50 degrees. Further
only 2 degrees on the right side. Plantarflexion was also
sensitizing the peroneal nerve while performing SLR
limited on the rig ht side (25 degrees) compared with
extended the discomfort and tingling into the lateral
the left (50 degrees). as measured with a standard
forefoot and toes. No increase in tingling occurred
goniometer. Active and passive ankle plantarllexion
when the tibial nerve or the sural nerve were sensi
with associated subtalar joint supination produced dis
tized during the SLR test (Butler.
was reluctant to move in this direction. Other active
2000; Magee. 1997). SLR testing on the left sid e was accomplished to 95-100 degrees with only a stretching sensation
foot and ankle motions were not quantified at this ses
reported in the thigh.
comfort in the lateral anterior anlde region and Tiffany
Remeasurement of skin temperature at the end of
sion because of lack of time. The end-feel of passive cal produced d iscomfort in
the physical examination demonstrated the coolness
the lateral ankle region before tension was perceived.
had extended up to the mid-posterior thigh. However
caneal inversion was soft
a nd
The end-feel of calcaneal eversion was normal. Passive
the resting pain level had not notably changed follow
movement of the forefoot around the midtarsal oblique
ing the examination.
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
o
The initial part of your physical examination was largely directed at assessing vascular structures.
So although I routinely check vascular structures. in this case I was initially struck by the coolness.
Is this a normal feature of your routine
colour changes and dryness. These observations led
examination for inversion injuries or were there
me to perform a more thorough vascular examin
particular cues that suggested the need for this?
ation (i.e. pulse check. capillary filling time and tem perature measurement) .
• Clinician's answer I directed my physical examination to include an assessment of vascular structures because her symp toms and history suggested vascular involvement and I wanted to quantify the vascular responses. Coolness of the foot associated with a mottled appearance in the depend ent position suggested some type of vascu lar involvement. Dorsalis pedis and posterior tibial
D
W hat was your early impression regarding the structures involved. particularly the nellrovascu lar tissues, and the associated pathobiological mechanisms. including the stage of healing?
• Clinician's answer The history and clinical presentation of signs and
pulses were normal (ruling out arterial occlUSion).
symptoms suggested a more complicated problem
but capillary filling time was longer on the involved
than just a lateral ankle ligamento u s sprain. Colour
sid e. Dryness. coolness and the mottled appearance in.
changes. cooler skin temperature and skin dryness.
the presence of normal distal pulses suggested abnor
along with increased sensitivity to mechanical stimu
mal regulation of small vessel blood flow. perhaps
lation. indicated neurovascular instability.
related to altered sympathetic nerve function (Rempel et al. 1999). .
Positive
neurodynamic
examination
findings
indicated increased irritability within neurovascular
Copyrighted Material
8 ANKLE S P R A I N I N A 1 4-YEAR-OLD G I R L
tissue s . whi ch was prob ably seco nd a r y to direct ten
indicate
sile forces at the time of injury. It appeared that the
that
the
clinical
presentation
is
"P not
en tire ly consistent with the more common syn
peroneal nerve ( both superfic i al and deep p eroneal
drome of lateral ankle Iigament.ous spra in.
sensory branches) was impl icated. The vascular
th an ignoring
structures involved may have included the lateral
symptoms
and
signs
Rather
that
are
unusual . dimcult to interp r e t or perceived as non
saphenous vein and possibl y the anterior lateral
contributory to a favoured hypothesis. the clini
malleolar artery. the peroneal artery. and/or the lat
cian has acted upon these findings and pursued
eral tarsal artery. The pathobiological processes in the
further data to enable him to test hypothese s
neurovascular tissues tend to suggest the persistence
related to tr a uma of neuro logical and vascular
of per iph era lly evoked neurogenic symptoms (input)
struc tures. desp i te the relative rarity of
and possibly centrally evoked symptoms (processing).
such
injuries . A non-exp ert therapist may have simp ly
as well as' autonomic and motor (outpu t ) involve
focussed on the obvious injured joint stru ctures
ment. as evidenced by the shaking of the toes.
and failed to recognize the potential signil1cance of
The lig a mento us tissue should have been in sta g e
some key clinical features (e.g. dr y ness of skin).
two of heal in g (subacute or granulation/fibroplasia
nor re a ll y considered why sy mptoms and signs
and just en terin g stage three of the h eal ing process ( remodel ling phase) because it was approxi
phase)
were persisting be y ond the expected timefra me for healing and nociceptive pain.
mately 2 2 days since th e second injury. Nociceptive
Consideration of where the p a tient ' s disorder is
pain should have resolved by this point in time.
with respect to the normal stages of tissue he aling is important in recognizing whether it is following a normal course of recovery. When this is not the
• Clinical reasoning commentary
case . it
The clinician has recogniz ed the likely S igni fi canc e
consideration of factors. including pain mecha
of those
I1ndings in
gestive of
a
the clinical examination sug
nisms as
al er ts
the reflective clinici an to further
discussed here. which may be interfering
w ith the healing processes.
neurovascular probl e m and which
BM'irfirfN9··I§i'_
more secure with an elastic bandage wrapped around
Treatment on the first day consisted of neuromobi
applic ation .
the ankle, she was encouraged to contin ue with its
lization exercise instruction. Tiffany was advised to
Considerable time was sp e nt dis cuss ing
perform 10 repeti tions of knee extension. hourly if
with Tiffany
and her mother the mechanism of injury and the tis
possible. without any prepositioning of the ankle.
sues that could have been injured. It was explained that
The exercise could be carried out either
the presence of neurovascular instability most Iil<ely
in supine or
sitting. She was in struc ted. along with her mother.
imp licated
to perform this exercise only to
which would probably lengthen recovery time. Options
a
sense of ini ti al ten
neurological tissues and
blood vessels.
sion and not iato pain. The aim of the exercise was
for ankle supports were also
to improve vascular Iluid dynamics and axoplasrnic
decided that the need would be better assessed during
now in a n on-pa inful manner. so as to enhance
the next couple of weeks.
the nutrition and mobility of the neurol ogical tissues.
instructed on how to assess skin temperature daily. par
It was hoped this non-painful afferent input would help to start the process of normalizing the neur a l
system. TUTany
discussed and it was
Tiffany and her mother were
ticularly following exercise. thus skin temperature '
acted as a 'comparable sign' for ti ssue stress response. They were informed that the exercise should not cause
was
also instructed to continue partial
weight be aring as tolerated using the axillary crutches. but not at the expense of increasing pain. She was
adVised to obtain an oversized soft slipper to provide protection to the plantar foot surface. Because she felt
the right foot to become cooler. Timeframes [or healing were also discussed. as was the probability of her com peting with in 2 weeks. which seemed unWmly consider ing her current functional status. However, follow-up assessment would be necessary to mal(e that decision.
Copyrighted Material
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT M ANUAL THERAPISTS
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
D
You have obviously spent considerable time
to reverse this process. particularly considering th e
discussing the problem and its management
return of vascular supply to the nerve and axoplas
with Tiffany and her mother.Why did you
mic fl ow. I expected the timeframe for connective tis
consid er this was necessary?
sue repair and remodelling to be in the order of months [or full recovery. I was not concerned t h a t the vascular component
• Clinician's answer
would result in necrosis because there were palp
Both Ti ffany and her mother were very interested in
able pedal pulses. I contacted the
the mechanisms of injury and healing. I felt that if
about my diagnosis. with which he concurred. and
they were both well informed they would be less anx
called him weekly to give him updates on Tiffany's
ious and better able to understand what needed to
progress.
refer r i ng
surgeon
be accomplished to remedy the problem. In ad dition. our health-care system limits the number of times
a
patient can be seen in the clinic. This situation neces
D
sitates the patien t taking responsibility for their own
plan to examine the patient further at later
care, with home ex ercise and self-management likely
visits? If so, what specifically were you planning
to be essential components of Tiffany's rehabilitation
to do?
programme. r try to empower the patient and show them what they can do to promote the healing process. Once they understand the healing process, I then show them
Did you consider the physical (objective) examination complete at this stage or did you
• Clinician's answer The examination was no t complete. I intended to
what they must do to accomplish their goals and
measure calcaneal in ver sion and eversion and to docu
improve their functi on In this case, the goals of home
ment her weight bearing by using a bathroom s ca le. r
exercise and se l f-man agement included:
also planned to evaluate her wei ght bearing with
.
• faci litating lluid d ynamics to assist in resolvi ng intlammation and to improve tissue nutrition • remodelling connective tissue with graded pro gressive movements • enhancing motor co n trol through repetitive move ment patterns.
the podoscope when possible and to look at the thor acic spine for possible dysfunction that might influ ence sympathetic fun ct i on I nability to weight bear .
was a Significant impairment preventing normal ambulati on
.
It was considered her weight-bearing
pattern on the podoscope and the magnitude of force on the scale could be used for reassessment. This was not possible on the first visit because of time
D
What were your expectations regarding the
constraints.
timeframe for healing and what factors in the patient's presentation influenced your thinking? Were you at all concerned at this time about the vascular component to the problem?
• Clinical reasoning commentary With the expert clinician, not
occur
ent on
• Clinician's answer
c lin i ca l
reasoning does
in isolation. While it is heavily depend
factors or attributes i nt e rn al to the therapist
(e.g. clinical experience. communication skills), it
I was hoping that in 4-6 weeks I would see functional improvement in her weight bearing and gait, taking into consideration the neural involvement Primarily. .
the neurovascular dysfunction influenced my think ing. I was not absolutely sure how long it would take
is also somewhat intluenced by factors external to
the
therapist.
inc l u ding
the attribntes of
the patient and the environment. Such factors are ev id ent in thiS case, notably
the Willingness of
Tiffany (and her mother) to participate in her
Copyrighted Material
8 ANKLE SPRAI N IN A 14-YEAR-OLD G I R L
management, the l i m i t a ti o n
on
the number of tre at
ments imposed by the health-care system, and the inevitable time restrictions of cl i nic a l work. It is apparent that the expt.rt: clinician's re a soni ng is
she
slightly uncomfortable at end - range compa r ed with left ro tati on.
•
At the second v is it
(5 d a ys l a t er) . T if fany stated that
had been faithful in carrying out her neuromobi
lization exercises and was able to pe r f or m them with
out
any notable increase in pain. She also reported
that she had only
e x pe rie n
ced on e tempo r a ry episod e
of numbness in the cU1Jde. which had ext ended up the posterior thigh.
On ex a m in a tion . the right calf was 3.0°F (1.6°C) coole r than the l e ft . but the posterior thig hs we re e q ual in tempe rature . Ti ffa ny was still using axillary crutches with a non-weight-bearing gait on the right side. A c t i ve and pass i ve
motion of the toes and an k le
were unchanged from the initial visit. During this ses sion . calcaneal i nvers ion and eversion were 35 degrees and 15 degrees bilaterally, respectively. Attempts to
activate the toes using a toe-curling exercise with a towel were unsuc c e ssfu l as a result of
discomfort and
lack of toe contTol . However, the colour of the foot in the dependent position w as improved . Ti rfa ny had no complaints or thor acic spine pa i n ,
but thoracic spine m obility was assessed because of
the possibility of associated symp athe t ic nervous sys tem inlluence (Blumberg et aI., 1997; Butler and Slater, 1994: Cl e la nd et a!., 2002). Active t h oracic
Fig.8.2
carried out in a collaborative framework with relevant parties: the pa tien t , her mother. the referring surgeon, as well as the funding body and the workplace (sec dis cu ssion of collaborative reasoning in Gh. ]).
spine rotation to the right was found to be limited and
Reassessin�n11.�nd' furttler . . treatment.. \I,"'1'. '(' 0 '. .....' 1i ,� . . " •
in!
The second tre a tment session involved neuromobi lization exercises for the sciatic and p eron eal nerves, and this was
c com p l is h ed without any a d ver se tis also instructed in how t o perform toe curls using a towel an d ankle motion (plantarllexion and dorsillexion) us in g a til t board while sitting. without incr e asin g any of the symptoms. She was issued wi t h an elastic stoc ki ng to re pl ace t he el astic b and a ge and told to a
sue temperature res p ons e (Fig. 8. 2). Ti ffa ny was
remove it if her symptom s i nc rea sed.
Thoracic spine mobilization was instituted with the aim of positively i n llu en ci ng the sympathetic nervous system to facilitate neu rovascula r s tabil i ty. The first exercise re quired the patient to be pos i t i oned in hook ly i n g with her lower thoracic spine over
a
crosswise-positioned foam roll, while h er hands were clasped behind her neck. She was instructed to take a deep breath while in a
curled position and then to
exhale as she lowered her up per thoracic spine to the table. She was c a u tio n ed not to move into signillcant pain nor to allow the lumbar spine to extend
d uring
this movement. This exercise was repeated three times at each thoraCic spine level up to '1'6. T iffany
noted that right thoracic rotation movement was easier afterwards and less uncomfortable. Tiffany and
Neurodynamic mobilization for the sciatic and peroneal nerves: (a) starting position; (b) sciatic mobilization only;
(c) peroneal mobilization added.
Copyrighted Material
I
C L I N I C A L R EASO N I N G I N ACT I O N : CASE STU D I ES FROM E X P E RT M A N U A L T H E RAPI STS
her mo ther were then instructed i n the use of an
A fo l low-up te l e p ho n e co nversation 2 d ays later
a i rbag for spi n al m o b i lization to be p erfo rme d i n the
with Tif fa ny ' s mother indicated that the new exer
supine lyi n g positio n . The second exercise i nvolved
cises were go i n g well and the el astic stock i n g seemed
the use a foa m rol l against a wa ll for thoracic soft tis
more comforta b le and effective th a n the elastic b a n
sue mob i l ization. The patient lea n s on tbe roll against
dage.
the wa l l i n a stan d i n g position a n d l1exes and extends
curl exercises because of lack o f motor control. The
tissues o f the
temperature pat tern of the r ight l eg was i mproving
the knees to move the ro l l over the so ft
Ti ffa ny was still u n a b l e to p erform the towel toe
spine. Ti ffa ny was able to perform th i s exercise with
and it was actually fee l i n g warmer. The colour of the
o u t difficulty wh i l e o n ly p ar tia l weight bearing on the
foot was improv i n g as well . The mother was
right leg. She tol erated thoracic spine self-mob i l i zation
to continue the p l a n of care a n d
without incident.
wo uld b e per formed a t the next visit.
a
adv ised
reassess men t
REASO N I N G D I SC U SS I O N A N D C L I N I CAL REASO N I N G C O M M E N TA RY
D
W h y d i d you s u s pect there c o u l d be
thoracic spine rotation to the rig h t side. If we could
i nvolve m e n t of the s y m patheti c n e rvous system
improve the n u i d dynam ics of the vasc u l a r s u pply
in an ap pare n t i nvers i o n i n j u ry? Could you
and the a xop lasmic llow i n the a re a , t hen this mig ht
please fu rther e l a b o rate regarding yo u r rati o n a l e
have a posi tive impact on the nu trition of the
fo r the tho rac i c s p i n e m o b i l izati on exe rcises ?
thetic fibres .
• C l i n ician's an swe r
• C l i n i cal
I wo u l d not rou ti n ely s uspect sympathetic nerve
The 'sho t
i nvo lveme n t but her symptom presentation s u ggested
spine to help to
sympa
reaso n i n g commentary
potential
in the dark'-that is, treat i n g the t horacic al lev iate the foot a nd ankle symp toms-is an examp l e of lateral th i nking on the part of the clinician. Although arguably an unlikely
fibres . This was rather a
a ssociation , despite the pathoan atomical rationale
d ark' but the rationa le relates to tho racic spine impairment i n nuencing the s ympathetic c h a i ns
processes tha t the profession al craft k nowledge of
w i t h i n that anatomical reg i o n (Blumberg et a l . ,
ma n ual therapy has
1 9 9 7 : Butler and S l a ter, 1 9 9 4 ; Cl e l a nd e t a I . , 2 0 0 2 ) .
(Butler.
that I consider that poss i b ility. The colour, tempera ture
and
sweati ng
c h a n ges
i nvolvement o f sympathetic
indic ated
' s h ot in the
given , it is largely through such lateral thinking developed. Neural mobil ization 20(0), repeated movements ( McKenzie,
I w a s trying t o s e e i f t here was a n assoc iation between
1 9 8 1 ) , mobilizations with movement (Mu lligan ,
thoracic spin a l mobi l i ty a n d her symptom complex .
have resulted 'outside of the box ' and reflecti ng about what t hey h ad found. Both the lndividual manual therapist and the community of manual therapis t s grow from suc h insights.
My hy pothesis w a s th a t maybe j oint a n d connective tissue res triction i n the thoracic spine m i g h t h ave h ad a contri b uti n g i nll uence on sympathetic d y sfunc tio n . This was suppor ted by the finding o f decreased
from a clinician d aring to thi n k
able to wear a sandal fo r the first time but still needed to
Outcome
• T h i rd visit
1 9 9 9 ) and many other interven tio ns
use crutches, a l t hough she could move aro und with some weight throu gh the foot. She a l so related that
( 1 week l ater)
her toes seemed to h ave increased sensitivity an d that
Ti ffany reported less colour ch a nge \!\Iith the depe ndent
her thoracic rota tion had improved and wa s more
foot position and that the foot was warmer. She was
comfortable.
Copyrighted Material
8 AN KLE SPRAIN IN A 1 4 - YEAR- OLD GIRL
Phys ica l ex amin ation revea led
ankl e mo tio n was
improving both in quality and q u an ti ty. espec i a lly right a n k le pla ntarnex ion ( 3 5 d e gr e es ) . The temperature o f the righ t c a lf was n ow o n ly l . oop ( 0 . 6°C)
coo ler than the left. C a p il l ar y mUng time in the right g re at toe was eq u a l to t h e left . Ti ffa ny was also able to f1ex he r toes a nd perfor m toe c url in g with a towel and pick-up p a ckin g popcorn with her toes. Thoracic spine right rotation was now equ a l to l e ft rotation w i t h o u t a ny d isc o mfo r t . The n e w fo u n d ab i li t y to bear we i g h t enabled the object ive assessmen t 0 1' we i g ht bearing usi n g a b ath room sca l e . R i g h t foo l pressure applied to a bath room s c a l e while s i l t i n g measu red 1 2 pou nds ( 5 . 5 kg) com pa red with 4 5 p ou n d s ( 2 0 . 5 k g ) o n the le ft . Ti ffany was even a b l e to ride a s ta ti o n a ry bi cyc le fo r 1 5 m i n u tes without pain. Ti ffa ny re c o g n i z e d a n d a c c e p t e d that p ar t i ci p a t ion i n the u p c om i n g cheerle a d i n g competi tion was not go i n g to be possible. She w a s instructed to con tinue her home exerc ise programme as prev i ously outlined and to u til ize a stationary b icycle. progressi n g up to 2 0-3 0 mi n u tes o f cyc li ng d a ily.
• Fourth
i'"
scale press test in sitting measured 18 p o u nd s ( 8 . 2 kg) o n the r i g h t side. Ti ffa ny 's wei g h t-bearing ability was fu r t he r evalu ated using a podoscope (a p lexi g lass sta ndin g box that al lows the opportu n i ty to observe an i n d iv i d u a l 's we ig h t - b e ar i n g patter n ) . S h e demon strated decreased pressu re in both t h e heel and fore loot ( P i g . 8 . 3 ) . T i b i a vara i o s i m u l a ted s i n g l e l i m b stance meas u red 1 0 deg r ees bilatera lly. T h i s compared favo u ra b ly with the c a l c a n e a l eversion of 1 5 degrees meas ured d u ring the second v i s i t . In other wo rd s . she did not have a v arus calcaneus t h a t would pred ispo s e her to a n ld e spra i n s . L iga m e n t testing of t he rig h t a n terior talofib u l ar ligament r ev e a le d s l i g h t l a x i ty c o mpa r e d with the left a n kle. A l e g - h i n d fo ot orthosis was fabr icated to prov ide stabiliza tion and proprioceptive input to the a n k l e r egi o n ( F i g . 8 . 4 ) . T i ffa ny was able to s t a n d mo re
visit ( 1 week later)
she was c o n t i n u i n g to improve and was p l ease d with her prog res s . She was able to place more we ight through the ri g h t leg during waU( ing; the colour of the foot was s ti l l i m prov i n g a nd it was becomi n g less hyperse nsitive . The mo ther had Tiffa ny repor ted that
noted normal temperat u res in the calf a n d ankle.
On e x a m i n a ti on . the tempera t u re patterns were now no rm a l . The righ t SLR had i m proved to 70 degrees before t ight ne ss was perceived and the n e u ro dynami c test for the perone al nerve was less provoca tive . Active right anlde dorsiflexion was now 1 0 d e gr ees
F i g. 8 . 3
a n d pla ntarnexion was 40 degree s . The b a t h room
heel and right forefoot p ress u re (arrow) .
Fig. 8.4
Leg-h i n dfoot orth o s i s : (a) l ateral v i ew;
(b)
Podoscope i mage d e mo nstrating d e c reased right
m e d i a l vi ew; (c) posterior v iew.
Copyrighted Material
C LI N I C A L R EASO N I N G IN ACT I O N : C A S E STU D I ES F RO M E X P E RT M A N UA L T H E RAPISTS
comfortably wi t h the orthosis and was able to ap ply
related that the bicycle exercise seemed to be very bene
5 0 pounds ( 2 2 . 7 kg) of force in a standing position
ficial and that pain was no l on ger a
without n o table pain pro du c ti o n . A t tttis point she
incl uding dur i n g plan tarfl exion and s u p i nati on of her
was advised to i n crease her weigh t-bearing activ ity. Addi tional instruction inclu ded various SLR exer cises (no weig h t and 1 0 repetitions per positio n ) ,
Si g nificant i s sue
.
foot. Her gai t was now accomplished without crutches and with o nly a slight limp. For long distances, how ever, she still preferred to use one cru tc h .
resisted a nkl e p l ant ar fl ex io n a n d thoracic ro tation
O n examination, the limp appeared t o b e related t o
u s i n g res istive e las tic exercise bands (repeated to
prolonged heel con tact dur i n g the terminal stance
fat igue) , and the use of a b at hr o o m scale for visual
phase o n the ri gh t leg. The bathroom scale test in stand
feedback on progressive wei g h t beari n g in sitt i n g and
ing prod uced 90 pounds (40. 9 kg) without pain on
s t an ding pos itions .
the right side. The podoscope examination revealed
Tiffany was also ins tructed to
s ti ll lacked
wear the l e g -hi n d loo t orthosis thro u g h o u t the day
improved pressure u nder the toes. but she
an d to watch for any s i g n s of s k i n irritation . She was
appropriate pressure under the fLrst meta tarsopha
encou raged to i ncrease her amb u lation and decrease
lan geal joint. No swelling was noted in the foo t and
her relia nce on the crutches .
anlde and the skin appeared healthy without evidence of dryness. Sl ight discomfort and weakness was noted
• Fifth visit ( 1
with res i s ted peroneus longus mu scle testing. Other
week later)
muscles tested around the anlde were normal . except for
Tiffany repor ted s i g n i ficant functi onal im provement
right gastrocnemius/soleus , which was sli ghtly weak
with ambu lation . She was able to ambu late with one
compared with the left . Right SLR reached 80 deg rees
cru tch for long distances and even ta ke
before tightness and slight lingling was produced.
a
few steps
without any ambu latory device for shorter dis tance s ,
all with o u t a n i n crease in pain.
Ti ffany was ins tructed t o cont i n ue her home exer cise progra m me and progressively inc rease stress to
The temperature patterns were nor ma l and shi ft
the tissues , al ways bei n g guided by pai n .
ing her wei g ht to the right leg in s ta n di ng registered 70 pou nds ( 3 1 . 8 kg) on the ba thr o o m s cal e . Ri g h t SLR was a lm os t equal to the left , and right anlde motion
• Fi nal visit (three weeks later)
had improved to 12 degrees for d orsiO exion and 4 7
Ti ffany had been re-evaluated by the re ferring phys
degrees for p l an t ar flex i o n without any pain. Tif fan y
ician since the prev ious visit. He was p lease d with her
was now able for the first time to stand on her right leg
prog ress and decided to di sch arge her from his care.
le g balance) for ap prox i mately 5 seconds while weari n g the orthosis . w i th o n ly one fi n ge r assisting
Tiffany no ted that pain was no lo nger an issue. She
her balance. The podoscope examination indicated
ing with prolon ged weight beari n g . It was re p or te d
( s i n gle
improved heel
and forefoot p ressure, but still lacked
good pressure under the fLr s t m e ta t ar so p h alange a l
experienced only occas i o nal arch fa t i gue and cramp the temperature, skin tex t u re and skin colour were normal, and she no longer n eeded the cru tch . Physical ly she demon s trated im p rov ed active con
j oint and toes. The addi tion of the o rthosis fabr icated du ri n g the
trol of her toe and ankle muscles . Neurodynamic test
previous v i s i t seemed to have Sig n i ficant ly improve d
in g of t he right peroneal nerve was improved to 8 5 degrees before the onset of tigh tness and s l igh t tin
Tiffany 's weight-bearing status. S h e was encou raged to con t i n u e her home exerci se programme and to
gling. Temperature patterns continued to be normal.
concentrate o n b alanC ing activities and a normal
Tiffany was able to ambulate w ithout the leg-hin dfoot or thosis , b u t she stUl felt more con fident w h i le wearing
heel-toe gait pattern using one crutch .
it. Her gait demo nstrated good
• Sixth visit (one week later)
noted was improving. S i n g l e leg balance was accom
Tirfany was now apprOximately 9 weeks post-inj ury and was able to wear a regular shoe
fu n c ti o nal velocity and
the late hee l-off in terminal stance phase previously
for the fLrs t time,
plished for abo u t 5 seconds w i thout a her balance. She still had difficulty
fi n ge r assisting pe r fo r m in g a heel
alt hough she continued to wear the le g-hindfoo t or tho
rise on the right leg because of wealmess and possibly
sis . She felt that the orthosis allowed her to ambulate
lack
more effec ti vely and with min imal discomfort. S he also
revealed symmetry between the fe e t (Fig. 8 . 5 ) .
Copyrighted Material
of
confidence.
The
podoscope
examination
8 A N K L E S P RAIN IN A 1 4-YEAR- O L D G I R L
(proprioce p t i o n )
and
neuromobilization
exerc ises .
S h e was a lso instructed in r e t r o -w a l k i n g and ec ce n tric l o a d i n g exercises for the a nkle pl a ntarfl e xor s to fa cilit a te s tren g t h e n i n g of
the non-contractile tissue
components as we ll as the c o n tractile elements of the muscles . It was emphasized t h a t pa i n s h o u ld gui de her exercise and activi ty. She was also encoura ged to co n ti n u e monitoring temperature as a n indica tor of tissue stress .
Approx im ately 6 mo n t h s a fter the inj ury, Ti ffa n y participa ted in a cheerJ e a d i ng squa d competi tion w i t h o u t p a i n , using the leg-hind foo t o r t h o s i s , a n d fig. 8 . 5
Podoscope image demonstrating symmetrical heel
a n d forefoot pres s u re .
wi n n i n g the state c ha m p ions h i p for h e r schoo l's d ivi
sion. At 1 3 m o n t h s after the i nj u ry, s he considered herself to be 900ft) norm al and at 2 2 m on t hs a fter i nj u ry she cons idered herself to b e 9 8 % n orm a l . with
Ti ffany and her mo ther re lt c o n fident that s he
the o n ly compl a i n t bei ng s l i g h t nu mbness over the
could co n ti n u e on the h o me exerc ise p ro g ra m m e w i t h occas i o n a l t e l e p h o n e u p d a t es on her pro g re s s .
dorsolateral aspect o f the foo t . She continues to we a r
T i ffa ny
lea d ing activities.
was
adv i sed
to concen trate
on
b a l a nce
a sort ankle s u p p o r t d u ring p a r ti c i patio n i n che e r
REA SON I N G DISC U S SION A N D C L INICA L REA SON I N G COM MENTA RY
II
What is your long-term prognosis for
o rg a n iz e d . Expert cli n ici a ns possess a
Tiffany ?
cl in ic al pa t t e r n s d eri ved fr o m
a
rich store o f
combination of
pr o p o s i ti o n a l ( research-based) and non-proposi
• Cli nician's answer
t i o n a l (professional craft and person a l ) knowledge.
Ti ffa ny has a good long-term prog nosis . Des p i te h av i n g s i g n i fi ca n tly i n j u red mult i p l e tissu e s , she is now
fu l ly ru nctiona l . w i th o nly s l i ght persisting numbness over the superficial p erone a l ner ve d i stribu ti o n i n the roo t. However. her cheerl ead i n g a ctiv i ti es . which include t u m b l i n g , cou l d possibly open her up to rein j u ry in t he fu tu re. The ankle support s he uses pr o b a bly assists by prov idin g additional propriocep tive inpu t and g iv i n g her confid ence d u r i n g cheerle a d i n g
activ ities.
U s u a l ly. examination and man agement of a n kle spra ins i s straightforward given t h a t
most will
resolve t h r o u gh normal he a l ing processes, with
advice and minimal i n t er ve n t i o n typic a l ly bein g a l l that is requ ire d . Nevertheless. as this c ase
illus
trates , p r ob l e m s can present in mul tipl e ways ranging from simple to co mple x , as in a l l areas o f the b od y. Hence, there are no recipes for examina tion or m an ageme nt that will apply across the ful l spectru m of possib l e pr esentati o n s .
Recognition and m a n ag emen t of more complex a n k l e spra ins, as in th is case. requires adv a n c e d
• Cli n i cal
reasoning commentary
This case. like
the others, h i ghl i gh t s t he specia li z e d
knowledge
kn owledge manual therapists require to p racti se at the h ig h es t leve l . H owe ve r, as discussed in C h a pter 1 , it is not how much an i ndividu a l
of
som a t ic ,
neural
and
vascular
anatomy, pathobiological p a i n and tissue mecha
knows that i s
impor t a n t . but rather how that knowledge is
nisms , specialized exam i n ati o n proced u res ( e . g .
t herm ist or assessment. n e ur o dy n a mic assessment s pe c ific peripheral n erves , ankle and
bi as e d to
foot biomechanics a s sessment) a nd specializ ed
man agement p ro ced u r e s
Copyrighted Material
( e . g . o r tho t ics) . This
C L I N ICAL REASON I N G I N ACT I O N : CASE STU D I ES F RO M E X P E RT M AN UA L T H E RA P I STS
advanced knowledge i s not retained in abstract
kn owledge across different
academic con structs . I n stead expert clinicians pos
meanin gful way. This level of knowledge o rga n i za
areas
in
a
clinica lly
sess highly developed knowledge bases where these
tion c a n not be ach ieved from books or j o u rn a l s
d i fferent
alone.
a reas
of
knowledge
are
interli nked
Experts
a cq u i re
t heir clin ically
releva n t
that
kn owledge orga nization t h rough t h e i r n ever-end ing
the hypothesis categories discussed i n Ch apter 1 are
ref1ection a n d i n tegration of the ava i lable research
through clinical patter n s .
It is our belief
a usefu l strategy for fac ilitating
this linking of
and experience-ba sed evidence .
• References B l u mberg.
H . . Hoffm a n . u. . Mo h a dj e r. M .
a nd S c h e r e me t . H . ( 1 9 9 7) . Sym pathetic nervous syste m and p a i n : a c l i n i c a l re-appraisa l . B e h av i o ra l
and Brain S c ie n c e s . 2 0 .
4 2 6-4 3 4 .
Bu tler. D . S . ( 2 0 0 0 ) . T h e S e n s itive Nervo u s System. Ad e l a ide . Austra li a : Noigroup Press. Butler, D . S . and S l a ter.
H. ( 1 9 9 4 ) . Neural
i nj u ry i n the t h o rac i c s p i n e : a c o n ce p t u a l basis for ma n u al t h e ra py. [ n PhYSical T h era py of the Cervical a n d Thoracic S p i n e s , 2 n d edn ( R . Gra n t. ed . ) p p . 3 1 3-3 3 8 . Ed in b u r g h : C h urch i l l Livingstone.
Cleland , J .. Dura l l . C. and Scott, S . A . ( 2 0 0 2 ) . Effects of s l u m p l o n g sitting on
pe r i phera l sudomotor aod vasomotor fu n c t i o n : a pi l o t study. Jou r n al of M a n u a l and M an i p u lat ive Therapy, 1 0 , 6 7- 7 5 . E l ftman , H . ( 1 9 6 0 ) . T h e tra n sverse ta r s a l
Manter, J.T. ( 1 9 4 1 ) . M ovem e n t s of the s u b ta lar j o i n t a n d tra n s verse tars a l joints. A n a to m ic a l Record . 8 0 , 3 9 7-4 1 0 . McKe nzie, R . ( 1 9 8 1 ) . T h e Lumbar S p i n e .
joint and its c o n tTol. Clinical
Mec h a n i c a l D i a g n o s i s fi nd Therapy.
Orth opedics and R e l a ted Resea rch . 1 6 ,
Lower H u t t , New Zea l a n d : S pi n o l
4 1 -4 6 . Hard e n . R . N . . Baron, R . a n d Ja n i g, W. (20 0 1 ) . Complex Regional Pain S y n d rom e . Seattle, WA : [ASP Press. Jan i g . W. and Sta nton-Hicks,
M. ( 19 9 6).
Rellex Sympathe tic D ystr o p hy :
A Reappra i s a l . Se a tt le , WA : [ASP Press. M agee, D.J. ( 1 9 9 7 ) . Orthopedic PhYS i c a l As ses s me n t . 3rd ed n . London: Sau nders.
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P u b l ic a lions.
B. ( 1 9 9 9 ) . M a n ua l Thera py. ' N AG S ' , ' S NAGS ' , ' M W Ms ' , etc . . 4 t h ed n , Wel l i ngton, N e w Zea l a n d : P l a n e
M u l li g a n .
View Press.
R e m pe l . D . . D a h l i n , L. and Lu ndborg. G. ( 1 9 9 9 ) . Pathophysiol ogy of nerve compressi o n s yn dr o m e s : respo n se o f peripheral nerves to l o ad i n g . Jou r n a l o f Bone a n d J o i n t S u rgery, 8 1 A , 1 6 00-1 6 1 0 .
Headache in a mature athlete Gwendo/en Jull
�
!!! UBJE.f.TIVE EXA M INATION .
Shirley was referred by a sports physician who she had consulted regarding her asthma. She was also suffering from almost daily frontal headaches. She has been having regular phy siotherapy on and orr ror the past year in conjunction with massage but had achieved no permanent relief. She had a motor vehicle accident (MVA) .35 years ago at which time she frac tured her thoracic spine. Although Shirley had some cervical stiffness. radiographs had shown only mild exit canal narrowing with no deterioration in the past 5 years. The sports physician believed that the stifr ness was contributing to her headaches. Shirley is a 54-year-old female who owns and works in her own retail business. She is also an ath lete who trains and competes in canoeing and has been successful at International Masters Games level. She had been training and competing in canoeing ror 15 years but in the last 2 years she has suffered from asthma and has had to ease of[ her training. The asthma is now under control and sl1e is starting to train again more seriously. This is more for her recre ational pursuits and desire for fitness rather than to compete at international level as her work commit ments and other newly acquired responsibilities pre clude her from dedicating the required time for this level of competition. Shirley reported that she had been suffering from headaches [or a long time and they certainly may have started before her MVA .3 5 years earlier. How ever. since the accident . she has always had troubles with her neck in some rorm. including wry neck
episodes and neck stiffness. as well as headaches. She reported that orten she can limit her wry neck episodes by concentrating on relaxation. but if the episode does not ease quickly. she consults a physiotherapist and attains relief. She also injured her vocal chords in the car accident. resulting in a hoarseness in her speech. Her new responsibilities include quite a deal of public speaking and ror the past 6 months she has been consulting a speech pathologist to assist with these problems. Currently Shirley sufrers from almost daily headaches or variable intensity. Some are severe and she is unable to runction while they are in the intense phase. which can last for several hours. These severe headaches are not frequent and Shirley cou Id not give any particular pattern that related to their occur rence. The moderately intense headaches are the more frequent ones. They last ror variable times from a rew hours to the whole day depending on how well she can intervene with either medication or attempts at relaxation or neck exercise. Shirley felt that she surrered only one rorm of headache and that all headaches were the same. except ror the intensity. The headaches are right sided. unilateral and in the frontal. retro-orbital area. The neck pain is less specific and is more a feeling of general neck pain and stiffness. There was no pain or discomfort reported in the rest of the race. upper limbs. thoracic or low back area. The headaches. whether moderate or severe. are consistently on the right side and do not change sides within or between headache episodes.
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135
.
CLINICAL REASO N I N G IN ACTION: CASE STUDIES FRO M EXPERT MANUAL TH E RAPISTS
With the intense headaches Shirl ey reported that
Shirley rep orted that she tries to control and relieve
she was often nauseous and occasional ly vomited but
the headaches with s imp le an algesics or aspirin and
had no other as sociated symptoms when headaches
neck exercises (s tretching ) with variable success.
,
were either intense or moderate She has never suf .
fered a p rodroma in association with any headache.
There was a family histo ry of headache in that her mother had suffered from migraine.
headache w as variable.
She has not attended for physiotherapy over the
Shirley reported that she could w ake with headache
last 6 mo nths but in the preceding 12 months she had
or tlI ey could come on during the day. The headaches would start in the front al region. They never started
been receiving physiotherap y for her headaches. The physio therapy which consisted of ma nual therapy
as neck pain, but a stiff. sore neck always accomp an
and muscle stretching exercises, gave some tempor
The time of
onset of
,
ary rel ief but overall it had not had any permanent
ied her head aches. Shirley could not identify any particular provoca tive factors for her headaches or f a ctors that may pre
effect on her head ache condition. What she had noticed in the last 6 months was that her headaches
cipitate them. She could not pred ic t the onset of the
were a little less frequent and this she attributed to
severe headaches. Normally Shirley slep t on her side
returning to paddling , as weU as the postural advice
and used one normal sized pillow and one soft pillow.
and neck relaxation strategies taught to her by the
She consid ered that she was comfort a ble in bed and
speech pathologist
on the whole slep t well even though she could wake
Headaches were still suffered
in
her
speec b on
rehabilitation.
at le a st 3 or 4 days
with a headache. Her work involved a variety of activ
per week. It would be unusual for her to go for more
ities and a variety of tasks and she had not noticed
than 2 d ays wi thout
that any particular task either specifically aggravated her neck or was likely to produce
a
headache She was .
a
headache of some so rt
.
Shirley related that what she wanted was some exercises or strategies that she could use to alleviate or at least help her to control her headaches.
usually quite physically active d uring tbe day.
R EA S O N I N G DISC U S S I O N A N D C L I N I CA L REA SO N IN G C OMM E N TA RY
• the temporal p a ttern of the headaches, namely datiy,
At the conclusion of the subjective examination, what was your primary hypotheSiS regarding the cuss the findings that you thought supported this
exercises • sidelocking
hypothesis? What were the features that you
of
headaches
to
the
right
side
(migraine not infrequently changes sides)
considered tended to n egate this hypothesis?
• reduce d frequency of headache with increased physical exercise in the past 6 months .
• Clinician's answer There were certain features that were consistent with a cervical spine cause or contribu tio n to the headache syndrome, while others were not suggestive of a cer vical musculoskeletal cause of headache, based o n a combinatio n of knowledge of the available research based evidence of headache presentations and classi
fications and my own personal clinical experience. The factors supportive of a cervical cause or com ponent to her headache were:
The factors that tended to negate a cervical cause or compo nent to her he adache were:
• the headache onset was in the frontal region rather than associated with neck pain or stiffness (it is common for migraines to start in the head with later spread to the neck , with the opposite app lying for cer vical headache)
• some headaches were of such severity to prohibit normal function (this is more
common
w ith
m igraine)
• an in itial history of trauma involVing an MVA, which the patient associated with a 35-year history of neck p roblems
with variable duration and intensity
• eas ing of headache with relax a tion of her neck and
source of the headaches? Could you please dis
• provocative factors, especially mechanical factors involving he r neck, could not be identified
• a family history of migraine Copyrighted Material
9 HEADACHE IN A MATURE ATHLETE
Iff!
• previous p hysi ot h erapy to her n e ck appe are d to
accompanied by muscle dysfunction. Previous tre a t
assist the neck pain but not her headaches to any
ment had not specifically addressed any neuromuscu
great extent.
lar dysfunction and the presence of this d y sfu nction could be a major contri b ut ing factor.
EJ
Considering the chronicity of the problem, did you at this stage consider the pain mechanism(s) that may have been mediating the patient's symptoms?
• Clinician's answer about the patient and her condition, hypothesizing about pain mechanisms was not a pr iori ty It was con .
sidered that more informed consideration could b e given to the proposed pain mechanisms once Imow ledge of the presence or not of symptomatic physical
impairments had been gained from the physical exam ination. The chronicity of the headache was not a con cern at this time. Many cervical and freque nt common
he ada ches h ave lengthy histories. The length
of history of cer v i cal headache does not preclude a peripheral nociceptive source amenable to manu al and other t herapies and has not necessarily been
an
impor
tant factor in inlluencing treatment outcome in my past experience. The major aim at this time was to lTY to sort out if headache.
II
a
the patient suffered
The answer regarding initi al hypotheses
demon
strates that the clinician is actively attempting to
At this stage. with the amount of information obtained
migraine
• Clinical reasoning commentary
from a cer vical
migraine or a mixed he adache form.
from the subj ective examination to
di ag n o stic hyp othesi s of cervical he a d a che This is .
typical of the pa ttern recognition process com monly used by experts. In particular. her knowledge
of the pattern of presentation of c ervical headache. partly based on skilled. reflective clinical reasoning and partly research based, en ables her to recognize the significa nce of clinical findings matchi ng (or supporti n g) elements of the clinical pattern she holds in her
memory Importantly the clinician has .
,
also recognized fmdings that are inconsistent with (or which negate) the cervical spine hypothesis and has kept her mind open to the possib i lity of
From the history, were there any factors that you maintenance of the headache problem? In particu lar, were there any psychosocial or stress factors?
a
migraine he a dac he or a mixtur e of the two. That is.
she has not ignored the clinical findings that do not lIt with the primary cervical headac h e hy pot hesi s and has thus avoided committing
thought may have contributed to the onset or
a
common rea
soning error of being biased toward the favoure d hypothesis, particularly ifit is one usu a lly amenable to manual therapy. It is worth noting that so me potenti a l p athobio
l ogical mechanisms u nd e rlyi n g (and other fact ors contributing to) any cervical comp onent to the
• Clinician's answer There were no indicators at this time, or inde ed
match findings
elicited clinical patterns relating to her primary
headache have been hypothesized, as evide nced by
later.
consideration of degenerative jOint processes and
that there were any psychosocial or adverse stress
neuromuscular impairment . It is implied that fur
factors involved in the pathogenesis of this patient's
th er in formation obtained in the physica l examina
headaches. From the history of neck pain dating back
tion will be used to test these hypotheses. a s well as
to the MVA. there was every likelihood based o n
th e source of the headaches.
ava i l able evidence that there would b e degenerative
In add i tio n the clinici a n h as made the judg
changes in the upper cervical joints. The presence o f
m ent that there are no sig n i fican t psychosocial or
j o i n t pain and dysfunction would probably also be
stress factor s in the patient s presentation.
tEl
.
'
PHYSICAL EXAMINATION
Posture
S i tt.ing posture approached a n upright neutTal pos
The basic shape of the postural curves was unremark
ition. The shoulder girdles were sl i ghtly elevated.
able. with good head. neck. and thoracic alignment.
downwardly rotate d a nd p rotr a cted . The pectoral
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CLINICAL REASO NIN G IN ACT I O N : CASE STU DIES F RO M EXPE RT M ANUAL THERAPISTS
muscles were slightly hypertrophied and appeared
heightened activity palpable in the soil tissues: in the
tight. The bulk of the levator scapulae was evident.
anterior and middle scalene and sternocleidomastoid
The scalenes also appeared to be overactive. with full
muscles bilaterally. Both first ribs were slightly elevated
ness in the supraclavicular fossae.
and hypomobile. Some slight tissue thickness was detected around the C2--C3 and C3--C4 zygapophyseal joints on the right side.
Active movements The patient was currently experiencing no pain.
Passive physiological intervertebral
Cervical spine movements were as follows:
movements
• Ilex ion: full range of motion (ROM). no pain reported
There was a slight restriction in lateral Ilexion and
• extension: slightly restricted but with no pain. and
rotation bilaterally.
most notable at C2-C3
some hypomobility in the cervicothoracic region:
C3-C4. Some slight restriction in rotation
the pattern of return to neutral from extension
detected at CI-C2 bilaterally.
a nd
was
also
revealed a lack of control of upper cervical initi
Anteroposterior glides
ation of the movement • rotation left and right: 75% ROM with a general feeling of stiffness. but no pain • lateral llexion left and right:
50% ROM with
scalene tightness restricting movement. but
no
reported pain • upper cervical flexion: full ROM. no pain • upper cervical extension: full ROM. no pain • CI-C2 rotation left and right: some general restric tion. but no reported pain. Thoracic spine movements were unremarkable and pain-free. Shoulder movements were full range and pain-free. with the pattern of control of the shoulder
A slight to moderate movement restriction was found on anteroposterior gliding of the C2-C3 and C3-C4 zygapophyseal joints on the right side. and to
a
lesser
degree on the left side.
Posterior palpation Time needed to be taken to achieve adequate relax ation of the neck. There was thickening 0[' the right C2-C3 and C3-C4 zygapophyseal joints.
Posteroanterior glides Local pain of moderate intenSity and muscle reactiv
girdle revealing no obvious deficiency.
ity was provoked over the right C2-C3 and C3-C4 zygapophyseal joints. which were also moderately
Neural system
restricted to movement. These findings were evident
The Brachial Plexus Provocation Test (BPPT; Elvey. 1998) performed on the left and right sides demon strated no muscle resistance to gentle scapular depres
to a lesser extent on the left side. The cervicothoracic junction
was
examination
moderately
w as
hypomobile.
Thoracic
unremarkable.
sion. The completion of the tests was unremarkable and produced no pain other than a cubital fossa stretch. Opper cervicaillexion was not restricted. and the quality of the passive upper cervical flexion move ment was unchanged when the left or right upper limb was prepositioned in the BPPT position and when the left or right leg was prepositioned in
a
straight leg
raise position.
Tests of neuromuscular control The pattern of activation and holding capacity of the scapular synergists is tested by active repositioning 01' the scapulae onto the chest wall in the prone lying position (scapular retraction. depression and upward rotation).
w it h
no arm loading. Shirley's performance
was fair. with some unwanted contribution from latissimus dorsi. rhomboids. and levator scapulae
Manual examination
muscles. There were signs of fatigue after five repeti tions. The performance on the right side was slightly
Anterior palpation
inferior to that on the left side.
A poor ability to relax was noted. Anterior palpa
The pattern of activation of the neck Oexors and
tion of the discs was unremarkable. There was some
holding capacity of the deep neck Oexors is tested
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9 HEADACHE IN A MATURE ATHLETE
"0
with the patient in s u p ine ly ing. with the head and
and muscle reaction h ad decreased to a m i n o r level.
neck in
neutral position. Slow and controlled upper
a nd the j oint motion restriction had slightly reduced.
cervi cal Ilexion is performed to target incremental
There was n o change in the ROM of active cervical
pres s u re levels. w i t h the pres s u re sen sor inserted
la teraillex ion.
a
behind the neck and preinllated to 20 mmHg. Shirley's performance was poor. There was excessive recruit men t of the su perf icia l neck l1exors. as well a s visible recru itment of the p l a tysma muscle. She could not control
a
steady pressure reading beyond 22 mmHg.
Provisional diagnosis Shirley was likely to have a mixed headache form.
and even at this level she s howed ev idence of fatigue
with a c o m b i n a tion of migraine and
after three repetiti o n s.
ponent. Co nversely. the musculo skeletal dy sfun ction
a
cervical com
may have been underly ing the compl a int of neck s t i ff ness and neck disco mfort but not the headache. PhYSical examination s ugges ted right C2-C3 and
Reassessment
C3-C4 zygapophyseal j oint a rthropathy (segmental
During posteroan terior gliding of the right C2-C3
degenerative condition) and poor neuromotor control.
and C3-C4 zyga pophyseal j oints. the provoked pain
especi ally i nvolving neck Ilexor synergy.
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
D
Prior to examining the mobility of the neural
neuromuscular examination and what is your
system. were there any possible indications
interpretation of the reassessment findings?
suggesting that this may have been a potential factor contributing to the symptoms? If not. what was your reasoning for undertaking this testing?
• Clinician's
answer
Tes ting the cervical flexo rs and scapu l a r retractors a nd depressors has the side benefit of inducing reciprocal relaxation of the cervical extensor m u scles. i ncluding
• Clinician's answer
the deep cerv ical extensors such as the segmental
There were no partic u l a r ind icators that mechano
m u ltifidus. This allows the symptom atic jo i n t to be
sensitiv i ty of the neural sy stem was contribut i ng to
repalpated with pos teroa n terior glides. tem pora rily
the hea dache syndrome. The neural system was being
devoid of pro tective muscle gu arding. Pain provoked
screened [or a ny involvement to allow i t to be removed
and perceived motion are aga in evalu ated a nd com
from further consideration. It is also my pra ctice to
pared with the o riginal a ssessment. The result gives
attempt to exclude any l i m i t a t i o n of upper cervical
some approxima te indicatio n as to how much of the
flexion c a u sed by mechanosensitivity of neural struc tures. beca use if thi s is present it can influence the cra n iocervical
flexion
mu scle
test.
giving
origi n ally
p rovoked joi nt p a i n
and
restriction of
motion is c a u sed by reactive muscle spa sm and how
false
much is [rom articu l a r chan ges . This can help to guide
positive findings . Cond ucting these muscle tes ts with
trea tment a nd often gives a d irection for the bala nce
out due con sideration of any neural tis sue sensitiv ity
behveen the components of manual therapy and thera
(if present) can result in an u nnecessary aggr avation
peutic exercise.
of headache.
The t herapeutic exercise is aimed towards improv i ng neuromotor control. thus reliev ing the j oint of
D
What led you to reassess joint signs
provocative strains. When joint cha nges are not pre
(posteroanterior glides) following the
sent o r not marked, the amount o f m a n u a l therapy
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CLINICAL REASO N I N G IN ACTI O N : CAS E STU D I ES F RO M EXP E RT M A NUAL T H E RA P I STS
requ ired is often less or has more of a neurophysio log ical rationale than a mechanical one. In the case of
• Clinical reasoning commentary
this patient. the re-evaluation indicated that articular
The response regardi ng mechanosensitivity of the
changes were present. as the motion restriction was
neural system indicated that the BPPT was und er
perceived to reduce only slightly. However. as pain and
taken for three sep ar a te reasons:
provoked muscle reactivity had decreased substantially
• as a scanning strategy to rule out an unlikely
.
this gave a good progn ostic indication th a t decreasing adverse muscle forces could relieve the joint pain. This gave a ration al basis for. and indicated the poten tial value of. therapeutic exercise to retrain good neuromuscular control.
source ( neural structures) for the headaches • to enhance the validity of a subsequent impor tant clinical test used to evaluate the possible c ont ri bu tion
of neuromuscular impairment in
the precipitation and maintenance of any cervi cal component to the headache • as a precautionary procedure to eliminate the
In view of the patient's histor y of asthma, did you consider assessing the breathing
possibility of aggravating sensitized neural tis
pattern?
sues during the craniocervical l1exion muscle test and worsening the patient's headaches. Th i nking Simultaneously on several levels such .
• Clinician's answer This was discussed with the patient. The p a tient was well aware of her breathing patterns and control of air int a ke and exhalation. The speech pathologist and the patient were working on this aspect to improve her voice
control.
as
indica ted in this response. is typical of expert clin
and the patient was already
employing basal expansion breathing exercises as part of this management. as well as relaxation and postural control strategies An emphasis was placed .
in the treatment on relaxation of the sca lene muscles
ici a ns. The clinician is enhancing her efficiency and accuracy by maximizing the v a lue (or 'pay out ) gained from this test procedure. '
The decision to reassess joint signs (posteroante rior glides) illustrates how the information obtained from one test can be of use in refinin g hypotheses in several categories. and thus again demonstrates efficiency in thinking consistent with a maximizing principle [n this case. reassessment of poste roa nte .
.
especially in the re-education of the neck l1exors in the craniocervicall1exion action.
rior accessory movement following the cervical and scapular muscle testing provided information of value in the following hypothesis categories: source (cervical joint
hypothesis).
contributing
factors
Your provisional diagnosis appears to suggest
(neuromuscular impairment hypothesis). patho
two alternative explanations for the patient's
biological mechanisms (mechanical versus neuro
headache symptoms. What further information
physiological
would you require from the physical examination
(balance between j Oint versus muscular interven
joint
component).
management
in order to be more confident in attributing at
tion or manual therapy versus exercise therapy ) and
least some of the headaches to musculoskeletal
prognosis In order to derive the maximal value from
dysfunction?
one test response the clinician must undertake
.
re!1ective thinking both during and following each clinical encounter, so as to broaden and deepen the repertoire of maximizing prinCiples
• Clinician's answer I wou l d have been a little more confident if the man ual
examination
had
reproduced
the
headache,
although this in itself is not totally conclusive. I was prep are d to give
a
trial of treatment to help to clarify
the situation and to come to a more conclusive diag nosis. I was aware that prev iou s tTeatment had assisted
The c1inician's thoughts on
a
.
tria l of treatment
reinforce the notion that the treatment itself is often needed to establish the diagnosis/hypothesis m ore confidently when this hypothesis (source and/or contributing factors) is still provisional or tentative. Consequently. the trea tment and the subsequent reassessment of the patient's signs and symptoms
the neck pain but seemed not to make a substantial
are integral elements in testing the hypothesis as
impact on the headache symptoms.
part of the hypothetico-deduciive reasoning process.
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9 HEA DAC H E I N A MAT U RE ATHLETE
po s tu r al and deep supporting role of muscles that the exercises wou ld t arge t .
• Treatment plan Poor muscle function is likely to have had a predomi nant role in aggravating the C2-C3 and C3-C4 z ygapo physeal joints. This is s u ppo r t ed by the clin ical fi ndi ng that the rec ipro cal i n hi bition of the ex ten s o r muscles afforded by the tests of m uscle function led to a reduction in provo ked pain duri n g the ap pli cation of p ost eroa nte ri or g lidin g . This i n dicates the need for an em ph a s is in treatment on neuromus cular re -educ a tion and man u al the rapy to the s y mp tomatic join ts. The cervicothoracic r eg i on may also need to be mobilized as a poten tial co n tri bu t or to the pr o ble m .
Explanation of treatment exp l a in e d to Shirley t h a t my i n it i a l tho u g h ts we re t hat she wa s p oss i b ly s u f feri n g from either a mixed h ead ache form. wi th a m i xt u re of migraine and ne ck headache. or th at she was e xp e r ie nci n g frequent common migraine and had a separate and unr el ated pr o blem in her neck. T r eatme n t was capable of influ enCi ng headac hes arising from the neck b u t was u n likel y to have any marked effect on a ge nuine migraine component to her h e a d ache. In l i g h t of t he poor response to previous p hysical treatment in rela tion to any real affect on her h eadac h es . a trial of treatment was su gge s ted with cri tical appraisal of the results. The poorest resu lt wou ld be that he r com plaints of neck sti ffness could be lessen ed but there would be no c h ange in her headac he pattern. with the best result being e l i m i n a tio n of her headaches. The patient agreed to this approach . involVing a real istic a p pra isal of treatment ef fects . Explan a ti on was given as to the importance of cor rect muscle control a nd func t i on for the protection o f jOiots. The rationale pr ovid ed w a s t hat i f t h e j oints r egain ed go od muscle support. this wo u ld relieve jo int s train and pain: hopefully th is would. in t u rn. allevi ate the he ada c hes. As Shi rl ey was a spor tsperson and used to high - l oad exercise. time was taken to explain that the form of e xerc ise that she would be tau ght was different from e x erc ises unde r taken for streng th . endu rance or fitness. The a pproach e mph asiz ed pre cision and control. and an a n al o g y of ski l l train ing was given. The different fu nctional roles of various musc les w as ex plai ned . with an emphasi s on the I
Exercises . Upper cervical flexion
To control unwanted activity in the s u pe rfic i al neck flexors. the patient was t aug h t the rest position o f the mandible and retaught the pattern of slow and co ntro l led upper cervical flexion wh i l e in supine lying. The e m p h asis was on control and prec ision . and the 22 mmHg mark was ta r ge ted o n th e pres sure sensor ( atte m p ts at any higher levels resulted in re cruitme n t of excessive supe rfi c ia l m uscle a ct i vity ) . S h i rl ey was t a u ght to palpate the an ter i or neck region and to perfo rm the movemen t witho u t fee l i n g te n s i o n develo pin g i n the supe r ficial muscles. She was to practise the mo ve m e n t and hold the position for 10 seco nds.
Scapula 'setting' exercise
T h e s capu l a 'setting' exercise was retaught to the patient in prone lying with correction of the action an d with e m phasis on preCisi o n and contro l . The focus was on ge n tl y pOSitioning the sc ap ula back and down onto the chest wall and h o ld i n g the p O S itio n . The previ ous u n wan ted use of latissimus dorsi was corrected and the activity o f th e lower trapezi u s was inspected and palpated. Shirley was taug ht the exe rcise on the right and left sides sep arat el y.
Postural exercise
The use of these muscles was incorporated in a pos tural exercise in si tt i n g. First. the assumption of ne u tra l u pri g ht posture was t a u g ht with cor re cti o n from the pelvis to ach i eve a neutral upright pelvic p osi tio n with a no r m al l umbar lordosis. Shirley was then tau g h t to l ift her s c apu la ge n tl y to pOSition it bac k and do wn onto the chest wall. ri ght and then l e ft. a nd to hold the pO S i tio n . A submaximal effort was en cou r a ged . On reassessment. pa i n and muscl e reaction pro voked had decreased to minimal leve ls d u ri n g p o s te ro an te ri o r gl iding of the right C2-C3 and C3-C4 j oints. JOi n t motion restriction was still prese n t but reduced. Active cervical lateral flexion was u n cha n ged .
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C LI N ICAL REAS O N I N G IN ACTIO N: CAS E STU D I E S F RO M EXP E RT M A N UAL T H E RAPISTS
poi n t of fatigue . or when she co ns i d ered that she
H ome programme S h i r l e y was given written instruc tions for a home pro gr a mme ('or the three retr a i n i n g tasks: uppe r cerv i ca l fl e x ion . t he scap u l ar exercise i n prone l y i ng . and the
pos t ural exerc i s e . The upper c e r v i c a l Ilex i o n a n d sc a pu l a r exercises were t o be p e rforme d twice per d a y
.
The a im was to ac h i e v e 10 repe ti t io n s of e ac h exer
cise. holdi n g for 10 seco nds The i m p o r t a n c e of preci .
sion was emp h asi z ed and it was ex pl a ined that at the
cou ld not accurately con trol the exercise. she was to s to p r a ther t h a n rei n force a n incor r ect pa ttern . The postural exe r cise was to be p ra c t iced repeat ed ly during the d ay and cues to remind her to perform the action were discussed . These inclu d ed every t i m e she answered the t e le p hon e a n d a ny time she walked up stairs (both common activities in her d a i ly rou tine
a t wor k)
.
REAS O N I N G D I S C U S S I O N A N D C L I N I CAL REASON I N G C O M M E N TA RY
D
Your initi al managem ent in volved a detailed
exercise will ass i s t their c on d i ti o n a n d the pai n-rel iev
expl anation of likel y diagnoses. recommended
ing bene l1ts of re-educating musc l e control . wi l l also
treatment an d rationale. and req uired patient
assist with compli a n ce . Sh irl ey was a spor tsper son
.
contribution. Could you please elaborate as to
and more used to h igh-load exercise. The the rapeu tic
why you cons idered this important!
exercise was di re c ted towa rd m u s c le control and enh a n cin g the active muscl e support of the jOi nts. It is skill learni n g and e mph as iz es low- load e x erci ses with
• C linician's answer
prec ision and control . As this was d i frere nt to her con
I n fo r mi n g the p a t i e nt is an impor t a n t aspect of a ny
cept of exercising for strength . car eful exp l a nation
m a n agem e n t programme. The patient prese n t ed with
was co n s i d ere d i mportant for complia nce
an
e xpe c t ati on
.
from her referri ng doctor that tre at
m ent of her n eck would al leviate her headache. I was u nsure after the in i ti a l examin ation how muc h of the
head ach e sy n d rome was cervica l in o ri gi n
• Clinical
reasoning commentary
It was
The impo r t a nce of collaborative c l i nic al rea soning
undesirab le for the patie n t to have u nrea l istic expect
is emphasized by t hi s discou rse. Not only is effec
.
ation s of treatment and I a lso n eed ed a re a li sti c and
tive communication n e eded to ensure that the
critical evaluation o f tre atment effects to assist i n d i f
a ctive i n terventions
ferenti a l d i a g nosi s I also re q u ir e d of her
( exercise compliance). but the role o f the pa t ie n t in
.
ical
a ppr a i s a l
a
more crit
of t h e n a ture of her h ea d aches a nd
aggrava t i n g fa ctor s to hel p i n d i ffere nt ia l di a g nos i s .
are
r epo r t i ng
accu rately
performed appropriately the
behaviou r
her
of
head aches follOWing treatment and at o t h e r ti mes
In my expe r ience rrom seei n g patients with head a c he
is seen to be crucial in determining t he re lative
who h ave pre v ious ly received phy siotherapy or chiro
contribu tion of the cerv ical spine. Therefore. the
prac tic management without any rel ief. one of the
patient: is somewha t responsible for both t he
pri mary re a sons for the l ack of s ucce s s is that the
a gement
headache is n o t origin a t i n g from cer v ica l spine
Consequently. it is i mpo r t a n t t h a t t h e patient does
d y s func tion
of
her
p ro bl e m
and
its
man
diagnosis.
no t have inappropriate or u n realistic expectati ons
.
P a t i en t complian c e in the t herapeutic exercise
of the
c l i n ic i a n
and o f her
own
( a nd any o ther treatmen t) is obviously critical to its
rehabilitation proces s
pote nti al success. A fu ll expl a n a ti on as to how tile
required to ov e rc o me such problems .
• Treatment 2
F u rther treatment Further tre atmen t occu rred over seven sessio ns Each
.
r ole i n
the
a n d educatio n i s t h e tool
( 1 week later)
Re-eval uation
.
session i n vo l ved
a
re-evaluation of S h irley. further
treatment and a reassessment of her progress
.
S h irl e y reporte d that she had had heada ches on the 2
d ay s fol low i n g treatmen t . but for the l as t 5 d ays sh e
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9 HEADACHE I N A MATURE ATHLE TE
h ad been without h ea d ache. T h is was
a
breal< fro m
her no r m a l p a tt er n . w h i c h s h e fo und pleasing. T h e neck
ac h i n g
and
s t i ffness
h ad
not
percepti bly
c h a n ged . On p hysic a l exa m i n a ti o n , l atera l i1exion to the left
and right was s t i l l restricted to approxi m a tely 5 0 % range w i t h scalene tigh tness e v ident. Pos teroanterior glid i n g o f the righ t C2-C3 a nd C 3 -C4 j o i n ts provoked less pain and muscle reac tion t h a n at the orig i n a l assessmen t . a l t h o u g h hypomo b i l i ty was s t i l l present i n the j O i n t s . During the upper cerv i c a l l1exion task, S hi rley could target a n d hold a t the level of 2 2 m mH g
.
but ac ti v i ty 0 1' t h e s u p e r fic i a l l1 exor musc les c o u l d b e observed w i t h a t temp t s at any h i g her levels. Correc tion was needed w i t h speed o f performa n c e . S c a p u l a r set ting in prone ly i n g
w as
performed w i t h o u t s ufficient
prec i s i o n and u s ed l a t iss i m u s d o rs i .
Treatment The p a t ter n of i n teraction o f t h e d ee p a n d superficial i1exo[ muscles was again retra i n e d . Electromyogra phy (EMG ) b i o feedback was used for t h i s . in ad d i t i o n to pressure biofeedback ( F i g . 9 . 1 ) . The EMG was placed o n the s ternocleid omastoid a n d a nterior sca lene musc les. a n d S h i rl ey ' s task was to progressively ta rge t 2 mmHg incre m e n ts in pressu re wh i l e preve n t i n g a u d i ble feedback
from t h e EMG b i o feedback
machine. which would i n d icate i ncre a s i n g s u pe r fic i a l
F ig. 9 . 1
The c r a n i ocervical fl e x i o n acti o n (the
a n a to m i c a l acti o n of the deep neck fl exo r m u scles) performed i n supine lyi ng. The p ress u re cuff m o n i tors the s l ight fl atte n i ng of the neck that occu rs w i th the acti o n . T h e pati e n t i s i n s tru cted t o perform the u p p e r cervical
muscle activi ty. A level of 2 4 mmHg w a s achieved . The scapular setting action in prone lyi n g was reta u g h t and prac t ised . Both the correct and i n cor rect actions were used to help S h i rley to iden tify the
flexion acti o n to p ro d u c e a n d hold i n c re m e n ta l i n c reases i n p ress u re . The p rese nce of i n a p p ro p r i ate s u pe rfi c i a l fl exor m u s c l e activity is m o n i tored u s i ng electromyography.
correct action. The sittin g postural exercise was c hecked ( t h e action was too stro n g ) a n d cor rected .
In addition . treatme n t invo l ved mo b i lization of the
pressure biofeedback for home use. The home pro
r i g h t a nd l e ft C2-C 3 and C 3 -C4 jOints . using a combin
gramme was r e i n force d . w i t h targets o f 2 2 a n d
ation o f anteroposterior glides and segmen tal l a teral
2 4 mmHg s e t .
i1ex ion mobilization . T he cervicothoracic spine an d first rib were also mobilized.
• Treatm ent 3
( 1 week later)
Reassessment
Re-evalu ation
Lateral flexion demo n s trated better q u a l ity move
S h irley reported t h a t s h e was c o n tro l l i n g the neck
ment, althou g h the r a n ge was u n c h a n ge d . Postero
p a i n with the exerc ises, a l th o u g h she s t i ll had occa
anterior glides
sion a l neck p a i n . Notably, s h e had had no headaches
applied
to
the
right
C2-C3
and
C 3 -C4 j o i n ts provoked l i ttle p a i n despite the pres
in the past week.
ence of slight to moderate hypomo b i l i ty. Some tissue
Physical examination revealed that both left and
relaxation was perceived on p a lpation o f the scalene
right lateral flexion were sti U restricted to approxin1ately
muscles a n d fI rst rib a re a . S h i rl ey was loaned
half range. but s howed better qu aliLy of movement.
a
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CLI N I CAL R EA S O N I N G I N ACTI O N : CAS E STU D I ES FROM E X P E RT MANUAL T H E RAP I STS
Posteroanterior gl i d i n g o f the right C2-C 3 and C3-C4 j Oi n ts pr ovoked s l i g h t p a i n and mu scle reac tion, with reduced hy pomobili ty. Duri ng the upper cervicai llex ion task. Shirley could target and hold at the level of 2 4 mmHg. with a good qual ity of per formance evident. Scap u l a r setting in prone lyi ng was performed wel l and she could achieve 10 repetitions on each side hold i n g for 10 seco n d s .
Treatment In retra i ning the upper cer v i c a l flex ion action. use was again made of EMG and pressure b i o feedback, with the target o f 26 mmHg be i ng a c h ieved. A new k i n aesthetic task was in troduce d , i n vo lv i n g randomly targe t i n g pressu res between 22 and 2 6 mmHg w i th
Fig. 9.2
Cervical ra nge of m ovement exercises i n to
rotation m a i n ta i n i ng the prone l y i ng on el bows position w i th scap u l a contro l .
precis i o n . Scap u l a r setti ng retra i n i n g progressed to a posi tion invo l v i n g prone ly i n g while supported on the
ti ght a fter paddl i n g . b u t she w a s a b l e t o ease it w i th the exercises.
elbows. Emphasis was placed on setting the scapulae
La tera l flexion both d irectio ns was now approxi
and a ctivating the ser ratus anterior by drawing
ma tely 75% range. w i th an i n creas i n g lateral curve
the chest wall up to the scapulae and hold i n g the
evide n t . Posteroanterior g l i d i n g of the righ t C2-C3
positi o n . Two fur t her tasks were introduced i n this
a n d C3-C4 j oints provoked very li ttle d i scomfor t .
posi tio n : frrst. p a tterning o f the neck llexor synergy
although slight hy pomob ility persisted . D u ring the
through retrai ning the correct p attern of u pper cervi
upper cervical l1exion ta s k . S h irley co u ld target and
cal and cervicai llex i o n /exten sion a n d , secondly, per
hold at the level of 28 mmHg with a good q u a l i ty of
forming cervical rotati o n and lateral flexion ROM
performa nce. Similarly, sc a p u l ar setti ng i n prone lying
exe rcises wh i le m a i n ta i n i n g a neu tra l
( s u ppor ted o n the e l bows) was performed we l l .
head/necl(
ali g nme n t ( Fig . 9 . 2 ) . The C2-C3
and C3-C4 segments were again
mobi l i zed u s i n g anteroposterior glides and l ateral
Treatment
flexion. but with more emphasis o n the right-sided
Upper cervical flex ion action retra i ning again made
j Oints. The cer vicothoracic re g i o n was also mob ilized.
use of EMG and pres s u re
biofeedback to target
28 mmHg. The kin aesthetic task to test the accu racy of targeti n g pressures b e tween 2 2 a nd 28 mmHg
Reassessment Latera l flex ion quality of movemen t improved . with slightly be tter ROM . No pain was provoked on pos tero anterior gl iding of the right C 2-C 3 and C 3-C4 j o ints. a lthough there was some residual hypomobility. The home programme was changed to inco rporate the progressions to the exercises.
was
performed with the eyes open a n d closed. Scapu l ar setting retra i n i n g was rev iewed . w i t h i n s tructions g i v e n t o continue at the same levels, both i n the prone ly i n g a n d prone ly i n g o n elbows posi tio n s . Mo b i l ization of t h e C 2 - C 3 and C3-C4 segments was repe ated . mov i n g gen tly but more fi rmly to the end of ava i l able range. The cervicoth oracic reg ion
• T reatment
4
(2
weeks later )
was aga i n mobi l i z e d . with no table i m provement in tissue q u ality and movement of the fi rst rib are a .
Re-evaluati on Sh irley
reported
The home progra mme w a s ch anged to i ncorporate that
she
had
experienced
two
head aches in the p a s t fo r t n i g h t but was able to control
these progressions
to
the exercises.
I n add ition ,
Shir ley was to start using the press u re b iofeedb ack a s
them u s i n g the exercises. For one episode she h a d
a checking d e v i c e . r a ther t h a n as a tra i n i n g device. i n
requ ired a n a l gesic tablets. Her n e c k became a little
preparation for remov ing t h e aid .
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9 H EADACHE IN A MATURE ATHLETE
Reassessment
'If'
Active l ateral Ilex i o n was a g a i n u n c h a nged , b u t there was now s l i g h t d i scomfo r t on posteroan terior
No reassessment was performed .
• Treatment 5 (4
gl i d i n g o f the ri g h t C2-C3 and C 3 -C 4 j o i nts, along with the persiste n t minor hy pomobility. In fac t , the whole neck reg i o n was a l i t t l e less relaxed. The upper
weeks later)
cervical flexion task demonstrated a goo d q u a l i ty of
Re-eval uation
performa nce (could target and h o l d a t the level of
S hi r l ey repor ted t h a t her nec k h a d been good and she
28 mmHg) , a s did the exercises i n prone lyin g sup
had had no headaches . S he had been doing exe rcises
por ted o n the e l b ows.
and they were now p a r t o f her ro u ti n e . She was a lso wo rk i n g q u i te h a rd w i t h her p ad d l i n g tra i n i n g. Lateral
flex ion
uncha nged .
movement
Pos tero a n terior
bot h
gliding
of
ways
was
the
right
Treatm ent All the retra i n i n g exerc ises for mu scle perfo r m a nce
C 2-C 3 and C 3 -C4 j o i n ts was now p a i n - free. a l though
were
slight hypo mobility persisted . With the u pper cervical
M o b i l ization of the C 2 --C 3 and C 3 -C4 segments was
c hecked
and
the
performance
was
good .
flexion task. S h i rley cou l d ta rge t a n d h o l d ( fo r 10 sec
repeated, addres s i n g the hy pomo b i l i ty and s l ig h t
onds) a t the level o f 2 8 m m H g , w i t h a good q u a l i ty of
d i scomfo r t .
performance over the 10 repeti t io n s . T h e exercises
A m a i n tenance h o m e prog r a m m e w a s estab l ished .
performed i n prone ly i n g su ppor ted o n the el bows
Form a l exercises were to be performed once per day
were a lso performed wel l .
and postural exercises had been routi n e ly incorp orated i n d a i ly activity. T h e review was p l a n ned in 6 week s .
Treatment All retra i n i n g of muscle performance was performed
without the assistance of the b i o feedback devices.
Review
(6
weeks later)
Mob ilization o [ the C2-C3 and C 3 -C4 segments was
S h i rley telephoned to say she had to go i n terstate o n
repeated addressing the hy pomob i l i ty a n d preposi
b u s i ness a n d was u n able t o attend for the review. She
tioning the j o i n ts i n to lateral flex i o n . Mob i l ization o f
repor ted she had been feel i n g good and was perform
the cervicothoracic region w a s a lso repeated .
ing the exercises.
No fo rmal reassessment was u nder taken . The
A letter was written to the refer r i n g d o c to r.
home prog r a m me was a d a p ted to emphasize self mon i tor i n g strategies. The plan was [or o n e more treatment to assess the performance of the' exercises, a n d then u nder t ake a review.
• Treatm ent 7 (4
m onths later)
S h i r ley repor ted that she had been very wel l for about 3 months a n d so s h e then started easing o ff the exer
cises. Over the last 2 to 3 weeks the headaches h a d
• Treatment 6 (3
star ted to retu r n . She had stepped u p h e r exercises
weeks later)
and they were helping a ga i n , but s h e fel t that t hey
Re-evaluation
were n o t as effective as before a n d she w i s hed to h ave
S h i r l ey reported t h a t h er neck had been goo d , a n d she
them checked aga i n .
had experienced one mild headache, which she could control with the exercises . However, 2 days e a rlier she had awoken with a severe headache and vom i tin g .
Re-evaluati on
S he h a d tried t o re l ieve i t w i th exerc ise b u t w a s u n able
T here was sti l l some general reduction i n ROM o f
to do so, a nd so took some medication before i t even
rotation a n d l ateral Ilexi o n active movements, b u t t h e
tua l ly settled . She reported that she sti l l fel t a l i ttle
movement range h a d been retained. T h e right-sided
tight i n her neck b u t the experience had made her
C 3 -C4 joint was sli g htly p a i n fu l to poste r o a n terior
rea lise that s he was pro b a bly s u ffering from two d i f
glides b u t C2-C 3 was asymptomatic. The j O i n ts had
feren t forms of head aches.
n o t regressed to any Sign i fic a n t exte n t , with only
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C LI N I CA L REASO N I N G I N ACT I O N : C A S E STU D I ES FRO M E X P E RT M A N UAL T H E RA P I STS
s l i g ht res i d u a l hypomo b i l i ty persisting. The hold i ng a b i l ity d ur i n g the upper cervic a l ilex i o n task had decreased sligh tly at the ta rget level of 2 4-2 6 m mH g. She was also performing the exercise with too much
• Treatm e n t 8 ( 2 weeks l ate r) Re-eval uation S h ir ley repor ted o n ly havi n g h a d one headache i n the
speed . The scapular setting in prone ly i ng exe rcise
l ast fo rtnight. She was padd l i n g regu larly with no i l l
was s t i l l performed wel l .
effects . She h a d b e e n d o i ng the exercises routi nely and fe l t s h e ag a i n h a d t h em u n der con tro l . T h e ri ght C 2-C 3 and C3-C4 j O i n ts were asymptom
Tre at m e n t
atic but with residu a l sligh t hypo mobility. The sterno
A l l exerc ises i n t h e trai n i n g regimen were reviewed
cle i d o m a s toid
and cor rected . S h irley elected to a c q u ire her own
rela xed . She had re gai ned her holding abi l ity during
pressure b i o feedb ack device for home use as it gave
the u pper cervical !1exion task and could ta rget a n d
her feedback on performance a n d an incen tive c hec k .
ho l d 2 8 m m Hg. T h e scapu l a r gi rd l e exercises were
M o b i lization o f
bei ng pe rfor med we l l .
t he C2-C3
and
particu l a rly
the
C 3 -C4 segmen ts was performed . a n d the cer v i c o t h oracic re g i o n was chec ked . Self- m a i n tenance was restressed a nd S h i rley reported s h e now h a d
a
and
scalene
muscles
were
q u ite
T h e seU'-care prog ramme was fu lly re v iewed and rewri tte n
for the p a t i e n t .
S h i rl ey w a s forma lly d i scharged fro m treatmen t
good
u n d e rsta n d i n g of the effect of the self- m a i n ten a nce
b u t i n for m e d s h e cou ld c a l l fo r
exercises.
was nece ssary.
a
review if she fe lt it
REASO N I N G DISCUSSION A N D C L I N ICAL REASON I N G C O M M E N TA RY The i m p rove m e n t of n e u ro m u s c u l a r con trol of
ev idence (Beeton and J u l l 1 9 9 4 ; Jull et a l . . 1 9 9 9 ; J u l l
key m u s c l e gro u p s appears to be a p r i m a r y goa l
et aI . , 2 0 0 2 ) .
.
of you r m a n age m e n t. What were the reasons that l e d yo u to th i s treatm e n t dec i s i o n ?
Q
A t t h e early stages i n the patient's management,
Fo r exa m p l e , d i d you recognize a fam i l i a r patte rn
did yo u fo r m u l ate a p rogn OS i s ? What factors did
of presentati o n that you knew ofte n res p o n d e d
you weigh i n c o m i ng to this d e c i s i o n ?
favo u rably to t h i s i n terve nti o n ? O r d i d y o u base yo u r d e c i s i o n on research evi d e n c e ?
• C l i n ician's answer At the early stage, I was not prepared to olTer a prog
• C l i n ician's an swer
nosis. There was some improvement i n j o int signs and
J o i n t pain a n d dysfu nction w i l l always be accompan
mus cle fu ncti o n . b u t not e n o ug h to relate this con
ied by muscle dysfu n ction. whether i t i s a spi n a l or
clus ively
ex trem ity j o i n t problem. The assessment of S hirley 's
Headaches. as with many other pa i n s . ca n i mprove by
m u s c le system revea led very poor muscle control. The
virtue of the fa ct that the s u fferer has sought and
to
the
improvement in the headaches.
n a t u re and extent of this i mpai rment directed the
been offered an i n terventio n . A ny prognOSis i n th is
n a tu re and prescrip tion of the exercise programme.
case wo u ld be more valid a t a l a ter s t a ge when i t could
T here was also knowledge ga i ned from previous treat
be assessed whether progress was maintained over
ment that manual therapy alone. while giv i n g rel ief,
time and if sy mptomatic i mproveme n t was in line
did not address the neck dysfu nction in the long term .
with improvement in p hysic a l signs o f cerv ica l j O i n t
Resea rch i n to cervical headache has identified t h is
a n d muscle dysfunction .
pattern of m u scle dysfu nction and evide nce is emer g i n g of the e fficacy o f re-ed ucati o n of the m u scle dys
D
Is there a reas on why you decided not to
fu n ctio n in the management of cervical he adache.
reassess after treatm ent 4 a n d also afte r s o m e
Therefore. t h i s approach wa s a lso b ased on researc h
late r treatm ents ?
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9 H EA DAC H E I N A M AT U R E ATH L E T E
• Cl inician's answer
evidence as to
the clinical efll c acy of this i n tervcn
Reassessme n t of segmenta l j O i n t hy pomob i l i ty, as one
t.io n . However, i t is al s o c lear that th ere were i n d i
o f the maj n outcomes o f manual tre atment. was being
vidual clinical Ilndings from the e x a m i n a t i o n of
i ncorporated i n t h e tTeatment. There was no ex pect
t h i s patient
ation at this stage that l a tera l l1ex ion wou ld c h a n ge
the treatment i n this p a r t i c u l a r case. That i s , the
dra matical ly and it was not a primary outcome. ance of the exercise as i t was being ta u ght Its i m m e .
as
appropriateness o f
c l i n ician did not adopt a re c i pe - l i ke approach' b u t '
The muscle system was evalu ated by the perform d i a te effect on j o i nts was e v a l u a ted
that i n d i c a te d the
ma n u al
t h er a py la l lowed the exerc ise. There was no percei ved need to h ave a ny other re assessment at this stage.
instead adapted a pa r t i c u l a r t rea t m e n t
a pp r o a c h
to a n i ndiv i d u a l patient presentatio n .
The i m porta n c e o f reassessment i n the testi n g and reformu l a t i n g of hyp o t he ses is evident in the responses to the que s t i on s . A lthough at ti me s n o formal reasses sment h a s been u ndertake n , the
c l i n i c i a n is co n s t a n t ly i n terpreting the stream of
• Clin ica l
information that becomes avai l able d u r i n g the
reasoning commentary
This i n fo r m a tion l a rgely gu i d e s decisions related to hypo th e s e s in the cate gories of t re a t me nt ( i n c l ud i n g the need fo r pro appl ic a tio n o f t reatment.
The c l i n ician's t ho ughts suggest that the treatment decision to implement s p e c i llc n e u r o musc u lar exer
cises was i n flue n c ed by k no w l ed ge ga i n ed from both
g re s s i on or c h ange) and prognosis, as w el l as the
the clinical
source ( s ) ( s u ch as cervical j O in t s ) and factors con
past clinical e xper i en c e ( r e c og n i ti on o f
t r i b u t in g ( fo r example, n eu r om us cu l a r i mpair
presentation/ pattern together with as s o c i a te d usual res ponses
to
treatments)
a nd
from
ment) t o t h e he a da c h e .
research
Outcome
a milder ' n eck headach e ' b u t could rel ieve it with the
exercises. She was conscientious about the exercises S h irley presen ted w i th a c u t e h i p p a i n 9 m o n t h s later,
and there were not many
following
them.
a
canoei n g trip. S h e reported that she was
d ays that s h e fa i l ed to do
doing well with her head aches and h a d probably o n ly
Exami n a t i o n a n d treatment were d i rected to her
experienced one or two severe m i g ra i ne headaches i n
h i p problem and, a t the end of this sessio n , her neck
the time si n ce h e r l a s t v i s i t . Very occ a s i o n a lly, s h e h a d
exercises were re v i e we d .
R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R E A S O N I N G CO M M E N TA RY Was there any feature about this case that at any
palpation is insu filcient alone to j ustify thera py, as these
time in the course of the management was not
are symptoms common to many headache forms. For
enti rely consistent with you r expectation s !
S h i rley, there was clear evidence of cervical articu lar
and musc le system impairment, which j u stilled a tTi a l of treatmen t . There c an be q u ite marked overlap
• Clinician's answer
between the symptoms of freq uent common migraine
There were really no unex pected features of this case. It
withou t a ura and cervical headache. As in this case,
is not u ncommon for a patient to presen t with
a
when a neck condition is presen t it is o ften not pos s i ble
headache syn drome that is not clear cut and easily clas
to predkt the contribution of the cervical dysfunction
sillable.
I n such ca ses , it is necessary to have Ilrm evi
to the head ache from a n in i ti al assessment. Therefore, a
dence of the presence of a pattern o f impairment in the
trial of treatment is necessary as par t of the diagnostic
cervical articular and musc u l ar systems in order to j us
process. Although I was u n a ble to preruct the o u tcome
tify offering treatment directed at the neck dysfunction .
of treatment from the fIrst assessment, the outcome
The presence of some neck aching or tender ness on
was not unexpected but j ust the same very pleasing.
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C L I N I C A L R EASO N I N G I N ACT I O N : C A S E STU D I E S F RO M E X P E RT M A N UA L T H E RA P I STS
• C l i n i cal
reason i n g co m m e n tary
associated w i th knowledge as t o t h e best o p t i o n s fo r
These thou ghts revea l that the c l i n ic a l pattern for
treatment and the l i kely responses to t hese i n t erven
cerv i c a l headache recognized by the cl i n i c i a n was
t ion s ( progn osi s ) . This ind icates a
not j u st l i m i te d to diagnostic cues ( s i g n i fi c a n t c l i n i
kn ow led ge base
h i g h ly developed
per t a i n i n g to headache presenta
c a l I1 n d ings) and underlyi n g theoretical pathobio
t i o n s and a n active effort on the part o f t h e c l i n i c i a n
logical
t o c u ltivate t h i s knowledge through c l i n i c a l reflec
mec h a n i sm s . The fact that the
c lin i c i a n w a s
n o t surprised at any stage of the ma nagement
process su ggests that the
c l i n ic a l
pattern was also
tion and by the rel a tin g of cl i n ic a l experience to
research evidence.
• Refe re n c e s Beeton. K . a n d J u l i o G . ( 1 9 9 4 ) . T he effecti veness of man i p u l ative
in the m a n a ge m e n t of headache: a si ngle case
p hys i o t h e rapy c c r v i c ogenic
b ra c h i a l
plexus t en s i o n . A u s l ra l i a n
Jou r n a l o r Phys iothera py. M o n o g r a p h 3 . 1 3- 1 7 . Julio
GA. B a rrett. C . . Magee. R . and Ho. P.
s t u dy. Phys i o t herapy. 80. 4 1 7-4 2 3 .
( 1 9 9 9 ) . Tow a r d s c l i nica l c h a racteris a
R . ( 1 9 9 8 ) . Com m e n ta ry : t reatmen t of a rm p a i n associ<l ted with a b n o r m a l
tion
El vey.
of muscle dysfu nction i n c e r v i c a l hea d a che. Cepha l a l g i a . 1 9 . 1 7 9-1 8 5 .
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C . . Trol l . P . Po ller. H . ct a l . ( 2 0 0 2 ) . A r a n d o m i z ed c o n tro l l e d tri a l of exercise a n d m a n i p u lat ive therapy for cervicoge n i c hea dache. S p i n e .
Jull.
2 7 . 1 8 3 5- 1 8 4 3 .
T h o rac i c pai n l i m iti n g a patient's sec retari al wo rk an d spo rt Dian e Lee
�
S U BJ E CT I V E E XA M I N AT I O N
Ms Thomas ( Ju l ie) presen ted w i th p a i n i n three thor
After 6 weeks , Ju lie returned to h e r physici a n w i t h
acic locations that h a d com menced after a motor
reports of o n g o i n g p a i n t h a t c o n t i n u e d t o l i m i t her
ve h i cle acc ident. Eighteen months previously, she
activities. Prior to th is accident, she was a n av id s now
was on her way h o me fro m work when the veh icle she
skier and a sailor but she had n o t been able to return
was r i d i n g in ( fro n t seat p assenger) was b roadsided by
to any level of acti v i ty that involved p u s h i n g o r
another, which ran a stop s i g n . The p O i n t of impact
p u l l i n g w i t h her a r m s . Anticinfl a m m a tory medica
was just behind the passenger ' s d oo r. Ju l ie was
tion was prescribed and she was referre d for physio
wea ring a three-po i n t se at belt that activated such
therapy. Julie received u l traso u n d , heat and massage .
that the force of the impact d rove her thorax i n to
from which she fe l t o n ly temporary re l ie f. When a ny
right rotation a n d flex i o n . She remembers fee l i n g an
exercises were prescribed , she fo u n d both the local
immed iate s h arp pain on the left side o f her m i d -back
mid-thoracic pain and the l a teral costa l pain were
(pain one) .
aggravated. Julie c o n tinued to
work
as
a
legal
This p a i n was l oca lized l a teral to the spine a n d
secretary throughout this experience, althou g h she
med i a l t o the vertebral border of the left scapu l a . S h e
req u i red the use of a n a l gesic medication to complete
w a s ab l e t o g e t o u t of h e r vehicle, even tho u g h i t was
her d ay. The an ti-inll ammatory medic a t i o n began to
substantially d amaged by the i mpact. and im medi
aggravate her stomach a fter 3 weeks a n d so she d i s
ately no ticed that certa i n movements.
continued t h e m . A m i ld s e n s e o f i n d i gestion persisted
including
bre a t h i n g . aggravated her p a i n .
even a fter the cessation o f medica tion ( p a i n three ) .
Later that eve n i n g . Julie ' s p a i n bega n to spread as a deep ache a n d reached the left l a teral a spect of the thora x .
With respect t o her feel i n g s
regardin g
the e ffect
this problem was h av i n g on her life and i ts m a n a ge ment to d a te, Julie conveyed her distress about the
E a c h fu l l breath w a s accompan ied b y a sharp
non-resolution of her sy mp toms and the lim itations
shooting pain that ran fro m T 6 beneath the left sixth
they had i mposed on her l i festyle. S h e expressed s o me
rib to the rib angle ( pa i n two ) . Julie was sen t for X-ray
concerns regard i n g ever b e i n g able to retu r n to the
sca n n i n g by her attend i n g p hysici a n and no osseous
leve l o f sports she h a d previou sly e nj oye d : however,
abnorma l i ties were fou n d . She was advised that this
she d i d n o t appear to be p a i n focussed or exaggerate
was a 'soft t i ssue mj ury ' and that s he would heal in
her compl a i n ts . and her concerns seemed to be very
time. Over the next few months the i n te n sity o f both
appropr i a te and realistic. Both her home and work
pain one a n d pain two s o ftened somewhat but never
environ ments were good with fa m i ly, co-workers a n d
d i s ap peared .
h e r emp loyer a ll bei n g suppor tive.
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C L I N I C A L R EASO N I N G I N ACT I O N : C AS E STU D I ES F RO M E X P E RT M A N UA L T H E RA P I STS
Sy m ptom b e h av i o u r
When first see n , Julie 's pain was persisting i n i t s ori ginal location (pains one . two and three). Most move ments and/or sustained postures, particularly left rotation combined with extension of the thorax, aggravated the mid-thoracic and left lateral costal pains. Cervical movements on their own were not a problem. Julie felt that she had never been able to take a deep breath since the time of the impact. She was able to type for 1 0 minutes and to sit unsupported for
� J D
3 0 minutes. She frequently changed positions for relief. She woke often during the nig ht and her most comfortable place/position to sleep was semireclined in a chair. Screening with respect to possible precautions and contraindications to physiotherapy examination and treatment (e.g. general health. present and past medications, spinal cord . unexplained weight loss. cardiac/v isceral dysfunction, special investigations. etc. ) were all negative.
R E A S ONING D IS C U S SION AND C LINIC A L R E A S ONING C O M M ENTA RY
What were yo u r tho ughts at th i s stage ?
• C l i n ician's answer Possibly a mechanical dysfunction (joint shift or flX ation) had occurred during the impact and had not been cor rected nor spontaneously recovered. When an articular block is present. exercise tends to increase the local pain. When the problem is mechan ical . anti-inflammatory medication has l ittle long term effect since inflammation is not the primary source of nociception. Analgesic modalities do not affect the biomechanics of a blocked j Oint: therefore, any pain relief would only be temporary.
enjoys, this did not appear to be creating any dysfunc tional health beliefs or behaviours and I did not feel t hese emotions were going to interfere with her com mitment to recover y. I always include psychosocial considerations in the management of my patients since we treat human beings not j ust thei r body parts . I try to create a positive envi ronment with realistic expectations ( for both myself and the patient) so that treatment can be optimized . At th i s s tage of yo u r exa m i nation what were yo u r tho ughts regard i ng path o b i o l ogical pain mechanisms, s p e c i fi c a l l y did you fee l one m e c ha n i s m was d o m i nant! What c l u es i n the
With i n the hypoth e s i s catego ry 'activity a n d parti c i pation capab i l ities/restrictions', the pati e n t c l ea rly has a n u m b e r o f general fu n c t i o n a l l i m i tati o n s i n c l u d i ng diffi c u l ty b reat h i ng, typ i ng/ p ro l o nged s i tting, and any activity req u i r i n g pu s h i ng or p u l l i ng. In addition to th ese, we re there any psyc h o s o c i a l (e.g. cogn itive o r affe ctive) p ro b l e m s appare n t i n h e r p resentati o n ? C o u l d you b r i efly ex p l a i n wheth e r th ese were an i s s u e in th i s pati e n t's p resentation a n d if so
s u bjective exa m i nation have led you to th is i m p ress i o n ?
• C l i n i cian's an swe r The information supported my original impression that a j oint fixation was present. Her symptoms were aggravated by certain postures. thus implying a peripheral nociception and not a centrally mediated situation. The inability to lie down is common when a joint fixation exists in the thoracic spine.
h ow they i n fl uenced you r exa m i nation and m a n agem e n t.
With res pect to the hypothesis category of ' p recautions and contra i n d i cati o n s to exa m i n
• C l i n ician's an swer
ati o n a n d manage ment', cou l d you o u tl i n e t h e
I did not feel that Julie presented with a cognitive or affective problem. While she did convey a degree of distress and concern regarding her continued symp toms and inability to return to the activities she
key features at t h i s p o i n t that g u i ded yo u r p l a n s regard i ng extent of exa m i nation a n d choice o f treatm e n t. Specifi c a l l y we re there a n y p recau ti o n s o r c o n tra i n d i cati o n s ?
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1 0 T H O RAC I C PA I N LI M I TI N G A PAT I E N T ' S S E C R ETA R I A L WO R K A N D S P O RT
• C l i n i cian's an swe r
• C l i n i cal
There were no contraindications that I i de n t i fied from the subj ective exam ination . Precau tions are i mport a n t and whenever there is a l a te nt na ture to the symp toms or a sense of neural i nvol ve m e n t (lateral refer ra l of p a i n as we l l as poten t i a l neural mediated v i scera l symptoms) the ex a m i nation of the motions that stress the neura l system sh o u l d be approached w i th care. In other wo rds . no fo rcefu l movements a re used and symptom respon ses are mon i t o red with more time given fo r onset.
reason i n g commentary
Even in t.he opening moments
of
t he
patient
encounter. it is clear that the clinician is already beginning to formulate her thoughts on a broad range of hypotheses. with consideration given to t he patient's activity/participation restrictions
(i.e. phys
ical limitations in breathing and activities i nvolving push ing and pulling. as well as inability to resume skiing or sailing. with no psychosocial impairment apparent at this stage ) . dominant pain mechan isms (Le. no c icep t i ve). source of the pain (Le. local tho racic tissues), contributing fa ctors (e.g. motor vehicle
D
What were the range of hy potheses yo u we re c o n s i d e r i n g h e re for possi b l e s o u rces to each of the th i s lady's sy mpto m s ? Can yo u briefly i n d i cate of these what yo u c o n s i d e red most l i kely and why ?
accident. exercises) and prognosis (Le. not impeded by patien t s cognitive or affective status). '
Not all joint res triction s or fix a tions will be p a inful or stay painfu l . The neurological expl a nation for why some do and others do not must relate back to the extent of fixat.ion t.hat exists and the contribution of the other co n t ributin g physical, environmental.
• C l i n ician's answe r
processing and output mechanisms. which combine
At this point. I felt the symptoms were cOmi n g from
to form each patient's u n ique presentation. Th is
local tissues in the thorax rat he r than being referred
underscores the importance of a holistic reasoning
from the cervical spi ne since it was moveme nts from
approach that is d iagnostic in both a pathobiological
the thorax and not the cervical spine that were a ggra
a nd a narrative ( L e. seekin g to understand how the
vating. In additi o n . the qual ity of pain ( s h arp and fairly
problem has impacted on the pa t ient
loca l ized with i n the thorax and consistently agg ra
clinician ' s consideration of psychosocial fac to r s in
vated by certain movements) was sugges tive of a local
her assessment of patients problems highlights her
sou rce and not a referred one. I be lieve consistency,
attention to this key area of reasoning and to her
reproducibi l i ty
and
focussed location are qual i ti es of a
local source as opposed to
a
caused me to foc u s on her thorax was her breathing
s life) sense. The
'
patien ts' unique pain experiences.
referred source of pain .
A key p o i n t i n t h e subjective examin ation that
'
For Julie, the clinician has highlighted feature suppor tin g
a
a
key
nociceptive domi nant pai n
mechan ism . that i s the clear stimulus-response
comp l a i n ts . This i s comm o n when the biomec hanics
rel ationship between the patient's posture and her
of th e r i b s
a ffected and rare ly seen when thoracic
symptoms. a relationship also seen with the other
pain is refer red fro m the cervical spine. While i t i s not
aggravating activities . Long-term problems such as
are
possible to specify precisely which tissues are i nvolved
this often have or develop abnormal centra l nerv
b ased o n information fro m the s u bj ect ive exa m i n
ous system processing. However. when the sup
a t i o n al one, m y experience w i t h similar presen tations
porting evidence of a nociceptive pain mechanism
s uggests pain one was likely to be from a left zygapophy
pattern i s combined with the negating evidence of
seal j o i n t or costotransverse j O i n t in the mid-thoracic
an
region (T3-T S ) . Pain two could also be from these
nociceptive dominant pain mechanism hypothesis
a pp
are nt healthy psychosocial presentation . the
local somatic structures or quite possibly a neuro
i s l og ical give n the information avai lable at this
genic p a i n from an interco stal nerve on the left in the
stage. This is
m id-thoracic regio n , an impression supported by the
ties to access quite spec ific patterns of clinical pres
shooting n a ture of that pain . Pain three, the mild indi
entation. which is
gestion . was l ikely a direct result of a n ti-inl1ammatory
clinical ex peri e nc e (Le. pattern recogn iti on ) . It also
intolerance but could also h ave been a referred symp
illustrates the expert's ability to think on multiple
tom med i a ted by the sympathetic nervous system in
levels: in this case considering multiple hypotheses
the mid -thoracic spine.
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a
nice clear example of experts' abili
.
built up from years of reflective
C L I N I C A L R EASO N I N G I N ACT I O N : C A S E STU D I ES F ROM EX P E RT M A N UA L T H E RA P I STS
simult aneously and then refining them i n Ught of fur
light of t h e physical prese n tation t h a t emerges .
ther information (Le. hypothetico-deductive reason ing ) . As with all hypotheses though . and p o i n ted out
Simila rly. the response
to the ongoing man agement will fu rther support or negate this hypothesis and. in
by the clinician here. this represents only an initial
turn . contri bute to t he evolving understa nding of the
i m pression and wil l have to be considered further in
prob l e m a nd r eco gn i t i o n
tEl
of management req uired .
P H YSIC A L EXA M INATION
Po stu t"e On ex a mi n a t i o n of the spinal
curves . hypertonic i ty o f the erec tor spinae muscle wa s n ote d bila te r a l ly in the mid-thoracic region . This i ncreased activ ity was not segmental and tended to hold the mid-thorax extended rel ative to the c ervico t ho r acic ( C 7-T 3 region) a nd thoracolumbar r e g io n s ( T 1 1-L l ) of the s p ine. J u l ie's breathing pa ttern wa s s h al l ow a nd a p i c al .
F u n ct i o n al m ove m e n t and positional tests
B o t h the l e ft and right costo t r a n sverse j O i n ts ( s ixth rib a n d T6 ) we r e able to gl ide superiorly and i n feriorly. alth o u g h aga i n more forc e was requ i r e d to ach ie ve
fu ll motion.
Horizontal translation (T5 a n d left and right sixth ri b s rel ative to T6) was ma rke d ly bloc ked fo r right lat eral tr a n s l a t i on of T5 and tbe s i x t h ri bs rela tive to T 6 . with a bard end-feel t o t h is motion ( r i g . 1 0 . 1 ) . Le ft l a teral tra ns l a t i o n was l i mited co mp a re d with the seg ment above a n d below. with a softer en d-fee l th a n that o f rig ht lateral tra nslation ( r i g . 1 0 . 2 ) .
Wh e n Julie was exa m i n e d . all movements of the mi d th orax were l imited and a ' kink' i n the s p i n a l c u r ve was apparent a t the s i x th th o ra cic r i n g (T 5-T 6 and le ft a nd r i g h t s ixth r i b s ) . This k i n k was mos t apparent i n both right a nd l e ft rotatio n . On positional testi n g . T 5 w a s r i g h t rotated relative t o T6. The left s i x t h r i b was posterolateral re lati ve to t h e seve n t h a nd the ri g h t s i x t h rib w a s ante r ome d i a l relative to the s e v enth. T hese fi nd i n gs did n o t c h a n ge w h e n positio n a l a n a lysis was done i n nex i o n . neutral or extens ion o f the mid -thorax.
Passive p hys i o l ogical m o b i l ity tests (osteoki n e m atic fu nction) A l l mo t i o n s
(nexion, ex te ns i o n , left ro t a tio n right .
rota t i o n . left s ide nexion and right side l1ex ion) were limited with an end -feel of reactive muscle spasm.
r es tr i c te d i n all directions ( nex io n extensio n , left rotati o n , right rota tio n . left lateral ben d ing and r ight l a teral bending) when c ompa r e d with the levels above a nd bel ow.
The pas sive mobility at T 5-T6 was
F ig. 1 0 . 1
The b i o m e c h a n i cs proposed to o cc u r i n the
m i d-thorax d u ring right rotation of the trunk. ( R e p ro d u ced by kind permission of D e l ta O rthopaedic PhYSiotherapy C l i n i c . from Lee 1 994b.)
.
Passi ve stab i l i ty tests of at"th t"O ki netic fu nction
ex a m i n at i o n a l l t e s t s were n o r m a l for at T 5 -T 6 , be tween T6
Passive accessot"y m o b i l i ty tests
On the first
(at"t h t"O k i n e m atic fu n ction)
segmen ta l ar ti c u l a r st a b i lity
left a n d ri g h t zygapo physeal j oi n ts (T5-T6) were a b l e to g l i d e s u pe r i o r ly a n d i n feriorly, a l th o u g h more force was required to a c h i eve fu ll moti o n .
B o t h the
,
and sixth ribs a n d between t h e s i x t h r i b s and sternum 1 0 . 3 ) . Th e s e tests incl uded :
(Fig. •
ver tical (co mpressi o n . tracti o n )
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1 0 T H O RAC I C PA I N L I M I T I N G A PAT I E N T ' S S E C R ETA R I A L W O R K A N D SPO RT
Fig. 1 0 . 2
At the l i m i t of l eft l a teral trans l a t i o n , the
superior vertebra side fl exes to the right a l o ng the p l a n e of t h e p s e u d o 'U' j o i n t fo rmed by the i n te rve rtebral d i s c and the s u pe r i o r costove rtebral j o i n ts . ( Re p ro d u ced b y k i n d p e r m i s s i o n o f D e l ta O rthopaed i c Phys iothe rapy C l i n i c , from Lee 1 994b.)
• a n teropos terior. postero a n terior t ra n s l a tion T 5-T 6 • tra ns verse rotation left a n d right T 5 -T o
F i g. 1 0. 3
P a s s i v e t e s t fo r r i g h t h o rizonta l tra n s l ation
• a n terior tra n s l a t i o n T 6 /s i x t h ribs left a nd rig h t
s ta b i l i ty ofTS and the l eft and right s i xth ribs relative to
• a n teroposterior costoc h o n d r a l j o i n ts , sternochon
T 6 . T h e pat i e n t s i ts , arms crossed to oppos i te s h o u l d e r s ,
dral j o i n ts
a n d the t h e r a p i s t s ta n d s bes i d e the pati e n t. W i th the right
• horizontal tra n s l a t i o n l e ft a n d right T 5 and s i x t h
han d/a r m , t h e t h e r a p i s t pal pates the thorax such that the fifth fi nge r of the right hand l i es a l o ng the l eft s i xth r i b .
ribs/T 6 .
The transverse p rocesses ofT6 a re fixed with the l eft hand . A p u re right ho rizontal tra n s l ation fo rce i s a p p l i ed to
M uscle function tests
the t h o rax through the l eft s ixth rib. This w i l l tra n s l ate
G i ve n t h e m arked a r ti c u l a r fi nd i n g s . a complete m u sc le ba lance a n a lysis for s p i n a l stabi lization a n d
the s ixth r i bs and TS to the right relative to T 6 . N ote the q u a n ti ty of motion a n d i n parti c u l a r the e n d fee l of motio n . ( R e p rod uced by kind permission of
sc a p u l a r control was n o t d o ne on the fi r s t exami
D e l ta O rth opaedic Phys i o t h e rapy C l i n i c , from Lee
natio n .
1 994b . )
Neural function tests Conduction a n d m o b i l i ty were assessed.
Mobi l i ty . The fu ll slump p o s i t i o n aggrav a ted t h e l e ft
Conduction. All tests for u pper motor neuron con d uction
thro u g h the s p i n a l
cord
were
lateral costal p a in and t h i s p a in c o u l d be s e n s i tized
negative
(brougbt o n a n d re lieved) by vary i n g t b e positio n of
(Pla n ta r response tes t , clo n u s ) . The ski n beneath the
J u l i e s h e a d / neck when she was i n fu l l mid-thoracic
l e ft sixth rib was hyperse n s i tive to l i g h t touch a nd
11ex i o n . It right r o t a t i o n was ad d ed to the fu l l s l u m p
'
p i n prick laterally to the m i d - a x i l l a ry l i n e. There was
positio n , s he began to feel very u n we l l ( s l i g h t ly n a use
no evidence of d ecreased motor i n nervation o f the
ated) a nd a sympa thetic res p o n se could be prec ipi
left six th i n tercostal muscle.
tated i f this posi t i o n was sustained.
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,
C L I N I C AL R EASO N I N G I N ACT I O N : CAS E STU D I ES F RO M E X P E RT MAN UAL T H E RA P I STS
R E A S O N I N G D IS C U S SION AND C LINI C A L REA S O N I NG C O M M E N TA RY
D
Please d i sc u s s yo u r u s e of fu n c t i o n a l m ove m e n t and position tests, in particular you r interpretati o n o f a 'fixati o n ' .
• C l i n i c i an 's an swe r Fu nctio n a l movements tests eval u ate the qual ity o f movement. segme n ta l ly a n d collec t ively. d uring active range o f motion. The movements tested i n c l ude cardinal plane motion (pure sagittal . coronal and tra nsverse planes) or combined movements. Positio n a l tests are passive tests that i nvolve observa tion (looking) and palpation (feeling) of bones . We look for ma rked differences in the resting position of one bone relative to a c a rdin a l body plane as well a s relative t o one another. T hese tests help t o detect joint fi xations. With fixations we are t a Uei ng about a j Oint that i s held beyond i t s physi ological motion barrier and ye t within its anatomical motion barrier (it is not dis located ) . What holds it there? The j Oint becomes exces sive ly compressed by muscle forces . which d u ring the inj ury contract to prevent dislocation . Sometimes, like in the knee, an in tra-articular structure ( meniscus) can m a i n ta i n the j Oint fixation. More often, the posi tion is held by compression [ro m the muscles that cross the j o i n t . When a j oi n t is fIXated , the resting position of the bones d oes n o t c hange when i t is examined i n n.ex ion. neutral or hyperextension. By comparison. posi tio n a l c h a n ges that are the res ult of muscle imbalance frequen tly change from the extended to n.exion posi tion . thus the need to test in a ll three positio n s . Please e xp l a i n yo u r analys i s o f the p hysical fi n d i ngs and h ow they re late to you r choice of treatm e n t.
• C l i n i c i an 's answe r In order to ex pla i n the abnormal biomechan ics that have occurred here and , therefore. the c l i n ical rea soning behind the tre atment chosen . i t is necessary to u nd erstand what occurs normally in rotation of the mid-thorax. During right rotation of the mid-thorax (T 3-T8). the fol lowing biomech a n ics are thought to occur (Lee. 1 9 9 3 : 1 9 9 4 a . b ) . The superior ver tebra rotates to the right and trans lates to the left (see
Fig. 10 . 1 ) . Right rotation of the superior vertebral body 'pulls' the s uperior aspect of the head of the left rib forward at the costover tebral joint. i nducing anter ior rotation of the neck of the left rib (su perior glide at the left costotransverse j oi n t ) . and ' pushes ' the su pe rior aspect of the head of the right rib backwa rd . i n d ucing posterior rotation of the neck of the right rib (inferior glid e at the right costotran sverse joint) . The left l ateral translation of the superior vertebral body 'pushes' the left ri b posterola tera lly along the l i n e of the neck of the rib a nd causes a postero la teral trans lation o f the rib at the left costotransverse jOint. Simultaneously. the left latera l translation 'pulls' the right ri b anteromedially a long the line of the neck of the rib and causes an anteromed ial translation o f the rib at the right costotra nsverse joint. An a n tero medial/ posterolateral slide of the r ibs relative to the transverse processes to which they attach is thought to occu r during axi a l rota tion . When the l i m i t o f this horizonta l translation is reached. b o th t he costoverte bral and the costotransverse l igaments are tensed . S tability of the ribs both a n teriorly and posteriorly is requ ired for the following motion to occur. Further right rotation of the s uperior ver tebra occ u rs as the superior ver tebral body tilts to the r i g h t ( gl ides su per iorly along the left s uperior costoverte bral joint and inferiorly along the right superior costoverte bral joint). This tilt ca uses right side nexion o f the superior ver tebra a t the l i mit of righ t rotation of the mid tho racic segmen t (see Fig. 10 . 2 ) . I n Julie ' s case, the s ixth thoracic r i n g (T 5 -T 6 . the left and right sixth ribs and all of their related j o i n ts) was not able to tra nslate latera lly to the right. This dysfu nction i nvolved all fo ur bo nes of tbe sixth thor acic r i n g and was not j u st the consequence of a restriction of o ne zygapophyseal joint nor o ne costo tra nsverse j o i n t . The passive accessory mobility tests revealed full motion at the zygapophysea l jOints as well as the costotra nsverse j oi n ts. although a greater passive force was req u i red to produce the motion . This resistance to movement (as opposed to l ack of move ment) produced a kink in the mid-thoracic spinal cu rve during all of the fu nction al movement tests as well as i n the passive phYSiological mobility tests of the sixth ring. The marked block ( h igh resistance) to rig h t lateral transla tion o f the sixth ring preve nted
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1 0 T H O RAC I C PA I N L I M I TI N G A PATI E N T' S S E C RETA R I A L WO RK A N D S P O RT
the an teromed ia l translation of the l e ft six t h rib, re l a tive to the left tra nsverse process of T 6 , and the pos tero l a teral transl a tion o f the right sixth rib, rel ative to the right transverse process of T 6 , neces sary for left rotation o f T 5-T 6 and the s i x th ribs. During forced or sudden u ncontrol led rotation o f the mid-t horax. a segme ntal thoracic ring c a n become 'stuck' o r h e l d a t the limit of motio n . It is c u r rently th ough t that excessive compression of the articular surfaces occurs a t the moment of inj u ry, and th is compression m a i ntains the a l te red resting position. This compression i s the resu l t o f the central nervous system's response to t he sudden a fferent input i t is receiving from the defor m i n g a r ticu l a r structures. T h e central nervous system increases the segmental muscle ac tivity to preven t fur ther deform a tion o f the a r ticu l a r s tructures (Lee and Vleemi n g , 1 9 9 8 ) . This efferen t motor response is s u s t a i n e d by the distorted a ffere n t input from t he displ aced articu lar structu res . When the neura l tissue becomes sensi tized by the excessive central a fferent bombardment, fu rther lengthening of the system can provoke symp toms . This cou ld . in part. explain the positive slu mp test as wel l as the agg ravation of sympto ms with right rotati o n . A spontaneous efferent d ischa rge through the sympathetic system could be respo n s ible for the visceral symptom of nause a . Treatment, therefore, requires t h e normalization of the afferent input to the cen tra l nervous system such that the effere nt output to the segmental muscles ( a nd viscera) is red uced , the articu lar compression is relieved and the amplitu de of the j oint's neutral zone ( detec ted thro ugh passive accessory mobility testing of horizontal translation) is restored. In a biomechanical appro ach to treatment, this can be ach ieved through specific manu a l therapy followed by motor control re-ed ucation . With the p o o r re l i a b i l i ty of m a n u a l tech n i q ues to j u dge positional a l ign m e n t a n d m o b i l i ty, and the normal va riation a c ross the p o p u lati o n , h ow do you weight the s ignifi cance of yo u r m a n u a l exa m i nation fi n d i ngs i n reac h i ng a d i ag n o s i s a n d selecting a treatm e n t ?
• C l i n i cian's an swe r firmly believe ( b u t u n fortunately cannot prove) t h at when we test the i n ter-tester rel iability of a man ual techniq ue we often start by asking the wro n g
I
questio n . If t h e question is inappropriate, then the answer is not u sefu l . For exanlple, If we ask, 'How much is this jOint movin g? ' , we h ave to apply a stan dard of what w e think is norma l . In other words. is this j oint mov ing more. less or the same as we think it should . As you mentioned , there is a wide variation of movement possibilities across the popu lation and, therefore, a n accu rate answer to this question is impos sib le because ' norma l ' is a moving sta ndard . What a re we reaUy comparing the motion with? Even if we ask the questio n . 'Do I feel the same amo unt of movemen t as the next tester? ' , I must apply a scale of motion ( L e. norma l, sti ff. hypermobile) to categorize wha t I am feel ing. Where does the standard come from? Someone who writes a book saying each segmen t should h ave so many degrees o f motion? Where d oes this information come from and, given the wide variation of ' n orma l ' , how can one number be adequate? When we i nterpret what we are feeling i n terms of amount of movement, there will be less consistency between testers. Instead . we need to evaluate motion within the same individual by comparing motion to levels above and below and on the left and right sides . Instead of emphaSiz i ng the quanti ty of motion (Le. stiff or l oose) , whic h we know is highly variable and unrel iable, we should be exa mining quality of motion . This resistance to motion, or lack thereof. is a n examin ation of the size a nd shape of the neutra l zone of motion ((rom zero to R1 or first resist ance ) , wh ich every j O int has. This is a dy namic feature of a j oint's intern al and external environment and is u nder ar ticu lar, myo fascial and neural infl uence. Researching qu ality o f motion . and n o t quantity. may provide us with better re liability between testers. When you watch a n experie nced clinician work and ask them what they are feeling, t hey often say, 'Th i s joint doesn ' t feel right. i t ' s gu mmy, o r i t gives way too e a s i ly ' . The i n experienced clinician will try to inter pret what they feel i nto a quantity of moti o n , 'f think this j o i n t is stiff or hyperm obile ' . They h ave yet to develop a n inventory of 'common feel ings ' . I s u ppose this is what you ca l l pattern recognition of sensory input. This, for me, is the development o f skilled manual technique. So to a nswer the second part of you r question, I weigh the significance of my m a n u a l examin ation t1 n d i ngs (of resistance not quantity of motion) h ig h ly when reaching a biomechanical d i agnosis. I do not reach a diagnosis based o n the fi nd i n gs of one test but rather on the res u l ts of the entire exami nation process. I look for resistance to motion or giving way
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CLI N ICAL R E A SO N I N G IN ACTI O N : CAS E STU D I E S F RO M EXP E RT MA NUAL TH E RAPISTS
to implied fo rces and put less emphasis on the a m o u n t of moveme n t I a m fee l i ng.
diagnosis
on
the res ults o f the en tire exami nation
rather t. h a n any sin gle test. i L l u strates
a
key tenet of
rea so n i n g . t h a t is look i n g for consist ency /support
• C li nical
for hypo t h eses across
reasoning commentary
As d iscu ssed in Chapter 1 . physiotherapy knowl
edge
comprises
propos itional acq u ired
b i o m ed i ca l
research-va lida ted
knowledge/const r u cts .
non-propositional
n
n u m ber of II n d i ngs. Even
when some II n d i n gs are weighed more heavily than
empi r i c a l ly
knowledge/cl i n ical
others. this style of reason i n g m i n i mizes the com mon
of
error
overt'ocussing on yo u r favo urite
hypothesis and not excl u d i n g competi n g hypo t h e ses . S i m i larly. given that o u r knowledge of pa i n a nd
i n ferences a nd personal know ledge. It is i m p or t a n t
physical impairment is still fa r from complete.
to rel ate. where possible. o u r ex a m i n ation and
acknow led ged b y t he cl i n ician i n her prev ious com
as
t reatmen t i n terventions to the available biomedical
ments regard i n g the lack of t-isSlle spec i fic ity w i t h
knowledge, s u c h as the anatomical a n d b iome
physio t h e ra py procedures, it i s cri t ical t o monitor
c h emical rati onale o u t l i ned here by the c l i n i c i a n .
the effect of all i n terventions t h rough re- assessmen t
t h e c l i n i c i a n discu sses , some o f our
of loca l tissue. flUlction a l and psyc hosoci a l/q ual ity
j u d gmen t s . such as motion of a j o i n t , cannot be
of l i fe effect s . This aspect of clinical rea so n i n g t he
accu rately q u a n ti fied in
c l i n i c a l sett i n g . I n stead .
ory in practice i s evide n t in t he c l i n ic i a n ' s comments
t hos e c l i n i cians that carefully attend to sensory cues
regard ing re-assessme n t of horizo n t a l t ra ns l a t i o n
H o wever,
as
a
such as q u a l i ty of moveme n t and reflect ively relate
following
t hose p a t te r n s of sensory input to other features in
regard ing pa i n mec h a n isms, sources and ma n age
the p a t i e nt s presentation are able to learn from
men t strategy are fu rther tested . This crit ical level of
'
treatme n t .
whereby
her
hypot h es i s
their clIn ic a l experiences. The c l i ncian's comments
reflective reaso n i n g en ables therapists to c h a l lenge
regardin g the lim itations of movemen t tes t i n g .
their theories or presuppositions conti n u a lly and
a nd s u bseq u ent a pproach of b a s i n g her p hysic a l
adj ust their reaso ning appropriately.
fin ger. T6 is fixed by compressing the two seve n t h ribs towards the m i d - l i n e . Care m u s t be t a ke n to avoid fix a tion o f the sixth ribs , which m u s t be free to gl ide rel
• F irst treatment
ative to the tra nsverse processes o r T6. The o ther
In s i m p l e l a n g uage that Julie c o u l d unders t a n d , the
h a n d / arm l ies across the patient ' s crossed arms to
firs t treatme n t i nvolved exp l a i n i n g what had hap
con trol the thorax . Segmental loc a l i zation is ach ie ved
pened to her t h o rax . The symptoms were co-related
by flex i n g a n d extend ing the j o i n t u n t i l a neutra l posi
to
tion of the zygapophyseal j o i n ts i s ach ieve d . T h i s
her
p a th o b iomechanics
a nd
in
this
manner
patient/thera pist rapport a n d confidence was d e vel
localization i s m a i n ta i ned a s the p a t i e n t is rol led
oped . A fter 1 8 m o n t h s , the motor pattern that s u s
s u pi n e o n ly unti l contact is made be tween the table
tai ned the pathomec h a n ics was we l l established a n d
a n d the dorsal h a n d .
trea tment m a y wel l have provoked h e r symptoms i n i
From this posit i o n . T 5 and the l e ft and r i g h t six t h
t i a lly. T h e r e must be a good under s t a nding be tween
r i b s are tra n s lated laterally t o t h e rig h t t h rough the
patient and therapist if p a i n provocation occurs and
thorax to the motion b a r rier. S trong lo n g i t u d i n a l dis
trust i s to be ma i n ta i ned.
traction is app l ied thro u g h the thorax prior to the
A G r a d e 5 technique ( man i p u l a tive thrust) was
appUc ation o f a h ig h -ve locity, low-amp l i tu d e thrust.
u sed to reduce the ar ti c u l a r compre s s i o n . The specific
T h e thrust is i n
tec h n i q u e when the s i xth thoracic ring i s held in rig h t
p l a n e (Fig. 1 0 . 4 ) . The go al of the tec hnique is to
rotation ( le ft l a teral tra n s l a tion) is desc ribed bel ow. The p atie n t is in left s ide ly i n g , the head s u ppor ted
a
l a tera l di rection i n the transverse
tra nsl ate 1' 5 laterally and the left and rig h t six t h ribs r e l ative to T 6 .
o n a p illow and the a rms crossed to the opposite
A rter t h e sixth segmenta l r i n g was d ecompressed .
shou lders. With the left ha n d , the right seventh rib is
the fu n c t i o n a l moveme nt, positio n a l . mobi l i ty and
p a l p a ted posteriorly w i th the thumb and the left sev
stability tests were repeate d . No kink i n the spin a l
e n th rib is pa lpated posteriorly with the i n d ex or l o n g
cu rve was noted o n fu nctional move ment testing. The
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1 0 T H O RAC I C PA I N L I M I T I N G A PAT I E N T ' S S E C R ETA R I A L WO R K A N D SPO RT
Fig 1 0 . 5
I s o l a t i o n of the segmental s p i n a l s ta b i l izers can
be fac i l i tated u s i n g n e u ro m u s c u l a r s t i m u l a t i o n .
Fig. 1 0 . 4
G rade V m a n i p u lation tec h n i q u e used to
( R e p ro d u ced by k i n d perm i s s i o n of Delta O rthopaed i c
red uce a fixated l eft lateral s h ift of TS a n d the sixth ribs
Phys i o t h e ra py C l i n i c , fro m Lee 1 994b.)
relative to T6. Strong a x i a l d i s t racti o n m u s t be m a i nta i ne d t h roughout the tech n i q u e . ( R e p rod uced by k i n d perm ission o f D e l ta O rthopaed i c Phys iothe rapy C l i n i c ,
low bac k i nj ury, and t h a t recovery i s n o t spon ta neous
from Lee 1 994b.)
without spec ific exercise i nstruction. Cl i n i c a lly. the same appears to be tru e i n th e thorax . The p rin c i p l es
positi on a l tes ts revealed symmetry between T 5 and
T 6 as wel l as the l e ft and right s i x t h ribs i n n e x i o n
,
neu tra l and exte nsion of the m id-thoracic spine. The
pass ive p hy s i o log i c a l and p as si v e acc e s s ory m o b i l i ty tests
reve a led
less
r e s i s t a n ce
to
m o t io n
at
t he
zygapophysea l j o i nts between T 5 -T6 a n d the costo tra n s verse j o i n t s of the le ft a n d right sixth ri b s . A n u n d e r ly i n g i n s t a b i l i ty o f left l a tera l tra nslation ( h o ri z o n t a l ) a n d rig h t rota tion was d et e c ted A sense .
of g i v i n g way was fe l t d u ri n g l eft l a te r a l tra ns l ation as oppos ed to
a
larger a m p l i t u d e of motio n . In add i t i o n .
a tro p hy of the segmenta l stab i l iz i n g m u sc les ( rota
to res and deep m u l t i fidus) was noted .
The fu l l s l u mp position remained provocative, al tho u g h the pos i ti o n had to be held l o n g e r for the symptoms to be a g gravate d .
t a pe d to rem i n d Ju lie to avo i d rota tion in ei t h e r di rection (X t a p e across the T 5- T6 reg i o n ) . S h e was reminded that she ma y expe rience some i n crease i n b o t h her loca l a n d referred pain b u t that this wo u l d settle over the next 2 - 3 d ays a n d a The thorax was
sense o f i m proved mob i l i ty shou l d follow.
used in the th o r ax are identica l to those advoc a ted by
the research team [rom t h e University of Q ue e n s l a n d in Brisbane ( R i c h ard s o n et al . . 1 9 9 9 ) . Essentially, t he patient i s ta u g h t spec i fica l l y to recr u i t the s e g me ntal
mu sc le s i s om e trica l l y and t h e n 10. 5).
concentric ally while prone over a g y m b a l l ( F i g .
El e ctri c a l stimu l a t i o n c a n b e a usefu l a d j u nc t a t
th i s time. I n side lyi n g , spec i fi c se g m e n t al rotation c a n b e resisted by the thera pist both concentr i c a l ly a n d eccentrica lly to fa c i l i t a te t h e retu r n o f m u l t i fi d u s
fu nc ti o n . The programme is progressed b y i n creasing the l o ad the tho rax m u s t c o ntr o l. I n i t ia l ly, sc a p u l a r motion is i n troduced,
in particu l a r lower trapezi us
wor k . T he p atient m u s t con trol the neutral position
of the mi d t h o r ax t h r ou g h o u t th e s cap u l ar d epre s -
sion . The goal is to te a c h the p a ti e n t to isolate scapu lar motion from spi n a l motion so that the s cap u l a d oe s n o t prod u c e spi n a l m o t i o n d u r i n g activities
involving the arm. Once c o n trol i s g a i ned over the
scapu l a , exerc ises i n vo lv i n g the en tire u pper ex trem i ty may be ad ded ( F i g . 1 0 . 6 ) . By i ncre a s ing the lever arm and th en the load , the mid-thorax is fur ther c h alle n ged
.
Gymnastic b all , pro p ri o ce p t i ve . b a lance
a nd res is tive work can be i n te g r ated i n t o the p ro
gramme as needed . The velocity of the exerc ises c a n
S u bseq u ent treatments
be i n cre ase d a cc o rd in g t o the patien t s work a n d recre '
The fir st g ro u p of muscles that must be addressed in
a t io n
d e man d s . I n i ti al ly the load should be a pp l ied .
stabil ization t he r apy of t h e thoracic spine are the trans
b i laterally and then progressed to uni lateral work. At
ver sos p ina l
( m u l tifi d u s ) and erector spinae groups. Hides et a l . ( 1 9 9 4 , 1 9 9 6 ) h ave fo u n d that the d e e p
t h e c o m p l e t i on o f the programme. the patient should
llbres of mu l t i fi du s atrophy q u ickly fo l lo w in g an acute
sc ap u l a r motion
be able to isol a te specific spi n a l ex t e n s i o n wi t h o u t
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a nd control b o t h b i lateral a n d
C L I N I C A L R EAS O N I N G I N ACTI O N : C A S E STU D I ES F RO M EX P E RT M A N UAL T H E RA P I STS
very fe arfu l o f a ny ro tation fo r the next 3 d ays. She felt
a
sense of we ak n e ss i n her c hest accompanied
by a deep a c he when u nsupported i n s i t ti ng . S he was able to l e a r n specifi c a l ly to rec r u i t the deep seg mental stabil izers at T5-T6 very q u i ckly and pro gressed to scapul a r work w i t h i n 1 week. If she
the multifidus could be felt to ' s h u t down' or turn ofr. and
i n creased the lever arm or the load too qUickly,
she had d i fficulty sens i n g when this was happen i ng. This i s
a
d i ffi c u l t area of the spine for patients to pal
pate themselve s ; however i t is critical not to overlo a d the s p i n e beyond i t ' s ab i li ty t o Fig. 1 0 .6
The exercise p rogra m m e p rogresses fro m
cen tral s p i n a l sta b i l ization to i n c reased l o a d i n g with s c a p u l a r con trol and fi n a l l y u pper extre m i ty contro l .
ach ieve motor contro l .
Ju lie was keen to r e t u r n t o h e r sporting activities , all o f which req u ir ed u pper ex tremity pushing a n d pUl l ing. Our most
d i ffic u lt task was pacing the exerc ise pro
gra mme wi th o u t provoking fr ustratio n . T hrough o u t this prog ramme, the segmenta l ring remained ' u nsta
u n i lateral arm m o t i o n thro u g h o u t mid-ra n ge . They
ble' to static o r passive testing in r i g h t rotation and
are advised to avoid a ny act i v ity that places the m i d
left lateral tra n s l a tion . Over a 3 - month period , she
thorax at the l i mit of rotati o n in the direc tion of the i r
was able to learn to control her sp i n a l position and
instab i l i ty.
grad u a l ly i ncrease the loading through her upper
This was t h e programme of instr u ction given to
ex trem i t ies. U n i l a teral loading thro ugh one a rm ( l eft
m a n ip u l atio n . she repor ted
or righ t) , which i nvolve d thoracic rotatio n , rema ined
increased local mid-thoracic pai n , a decrease in the
provocative for her. She was able to return to a high
J u l i e . S u bseq u e n t to the
lateral costa l pa i n and no aggravation of her visceral
level of skii n g a nd as lo n g as she u sed both arms b i l at
sympto m s . She fe l t that s h e cou l d take a much deeper
era lly was able to manage the sail on her boat.
breath immed i a tely a fter the m a n i p u latio n . She used
U n i l a teral p u s h i ng or p u l l i n g ac tivities with her right
c a u t i o n w i th a l l l o a d ing throu g h her thorax and was
arm r em a i n s provocative.
REASO N I N G D I S C U S S I O N A N D C LI N I CA L REASO N I N G C O M M E N TA RY At your fi rst treatm e n t ses s i o n , you seemed to
(pain) or prinCi ples of stabilization therapy. When
p l a c e a l o t of em phasis on ex p l a i n i ng the p ro b
exerc ises are done with awareness of what is. or
l e m to th e patient. Can you co m m e n t on t h e
should . be happening, lear n i n g is facilitated . The non
ro le you see of teaching a n d exp la nati o n i n yo u r
thoughtfu l appro ach to exercise
pati e n t m a nage m e n t ?
in this manner. t h ree times per day regardless of how
( mo ve 2 kg 10 t i mes
yo u fee l or how you achieve the task) can be da nger ous or, at min i m u m . may merely reinforce the poor
• C l i n ician's answer I
motor
h ave found that the more the patient und erstands
regard i n g t heir condition , the more foc ussed and com
prog ramme
that
is
m a i ntaining
the
dys
fu nctio n . So. right [rom the begi n n i n g . education is a cri tical par t of the rehab i l i tation p rocess.
m i tted they become i n the recovery process. Le arn ing requires concentration and foc us; i n other words , a
Havi ng d etected the u n d e r l y i n g i n s tab i l i ty,
patient must be aware of t he processes t h at are occur
p l ease elaborate o n yo u r rati o n a l e fo r
ring i n their bod ies i n order to effect a change. This is
yo u r fu rther manage m e n t with t h i s
true whether we a re explai n i ng symptom behaviour
pati e n t.
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1 0 T H O RACIC PA IN LI M I T IN G A PATI EN T'S S E C RE TA R IAL WO RK AN D S P O RT
' awareness' compon e n t o f the exercise to re-estab l i s h
• Clini cian's answer Physiotherapy cannot restore articular integ rity ( form closure ) : there fore, the emphasis of t r ea tment must be
appropri a te neura l con necti ons
.
on the r estoration of motor control ( force closure)
• Cl i n ical
( V leemin g et a1 . . 1 9 9 0 a , b ) . The go al i s to con trol the
The importance the c linician places on the pa t i en t s
excessive neu tra l zone of lateral tran s lation and rota t ion d uri ng fu nctio n a l activ ities and to avoid the end
ranges of rotatio n , thus limiting the chances of fur ther ar ticu lar compression . This is accomplis hed thro ugh specilk exerci ses a u g m e n ted Vlrith muscle stimul ation . See ing how the onset of this lady's symptoms was trauma, do you feel th e re were any contributing factors (physical, environmental/ ergonomic,
reaso n i n g c o m m e ntary '
understanding and learning is consistent with the significance of pat ien t cognition i n t he mature orga nis m model h ighlighted in Chapter 1 . Patients' u nd er sta nd in gs and feelings are now recognized as signific a n t aspects of their pain experience, con tributing to their u n ique presentation and potentia l for recovery. Evaluat i n g patients' u nderstandings as potential con tributi n g factors to their health and also as a necessary prerequisite to guide the expla
psychosocial, etc.) that were partly res ponsible
n ation and ed ucation that wiU be required t o effect a
for p ro l on ging h e r sym pto m s and disab i lity ?
ch a n ge in their health a ttitudes and behaviours is an i m po rt a nt focus that must be incorporated in therapists' reasoning. That i s , improving patients'
• Clinician's answer This
was
a
straigh t forwa rd
health requ ires much more than physical d i a g nos
situation
where
the
tic reasoning: t h er ap ists must also be able to recog
trauma most l ikely resulted in a j o i n t fixation that d id
nize the other psychosocial and environ mental
not resolve spon taneou sly. as some wi l l . resu lti n g i n
determinants of hea lth and use their skills as teach
conti n ued sy mptoms a n d disabil i ty. While y o u would
ers to effe ct the necessary ch an ges . This di m e nsion
ex pect a muscu l oskeletal soft tissue i nj u ry to complete
of our reasoning is promoted when clinicians adopt
its healing muc h sooner t han the 1 8 months this
a broader model of health a n d disability, as encour
lady's sym ptoms h ave persisted , i t has been my experi
aged in the mature organism model, and practise
ence that such prob lems c a n frequently be ma in t ai n e d
the sh ared decision-making strategy de p ic ted in the
this long wh en a j o i n t fix ation is present.
collaborative reasoning mode l
When recovery does not occur when expected ,
.
The c linician's answer to rea s o n ing question 3
patients begin to fe ar t h a t they will never get com
n icely highlights how impairment in the mind-body
ple tely be tter This fea r c a n lead to psychological
connection can manifest not o n ly as an un h e l pful
states that can a mpl i fy the symptom ex perience.
perception , contributing to or d riving a patient s
Ch ron ic pa i n from a body p a rt can res u l t in d i ssoc i
pain , but also as faulty motor programmes , as
ation i n the bo d y- m i nd connection. Even a fte r the biomec h a n ics are restored , the body-m i nd con nec
reflected in a patient's learned postural an d move ment patterns. Again teaching as a focus of reaso n
tion must be addressed ; this is not necess ari ly auto
ing becomes important. Education to alter a patient's
.
'
matic. Exercises for ra nge of motion , or wh a t has
awareness is central to this clinician 's approach in
been called ' m o tor prog rammi n g ' or seq u encing of
promoting improved motor programmes and is con
movement patterns ' , sho u ld be ta ugh t emphasizing the
sistent with modern theories of learning.
'
,
Outcome
segmen t al r i ng
is v u l nerable s h o u ld
s h e susta i n
a n other ri ght rotational i nj ury. f n the mea ntime, she J u l ie sust a i ned a n inj ury that caused a s tatic instabil
has received the education she needs to m a i n t a i n her
ity of her mid-thorax. The pass ive structures t h a t
dy n a m ic stabil i ty a n d i f she conti nues to take care o f
restr ai n ri g ht rotation and left la tera l tra nslation h a d
this segme n t and c o n trol the d e g ree o f
become s tretc hed an d s h e req u i red a n optim al force
thro u g h th is part o f her spine, she s h o u l d be able to
closure mec h a nism to re m a i n functio n a l . The T 5 -T6
c on trol her sy mp toms
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C LI N I C A L R EASO N I N G I N ACT I O N : C A S E STU D I E S F RO M EX P E RT M A N UAL TH E R A P I STS
â&#x20AC;˘ References H i d es. JA .
Sa i d e . M .. Ju l l . D. H. ( 1 9 9 4 ) . Evidence o f l u m bar m u l t i fidus m u sc l e s wa s t i n g i ps i l a te r a l to symptoms i n p a t i ents w i t h Stokes. M . J . .
C A . Coo pe r.
Cervical a n d Thor a c i c Spine. 2 n d edn
( R . Grant. ed . )
pp. 4 7-0 4 . New
C b u rc h i l l Livi n gsto n e . Lee.
D.G.
(l 9 9 4 b ) . M a n u a l Therapy
a c u te / s u b a c u te low b a c k p a i n . S p i n e .
the T horax-a Biomec h a n ical
1 9 . 1 0 5- 1 7 7 .
Approa c h . De l t a
I-T ides. JA . R i c hard s o n . C . A . .
lu l l. C . A .
( 1 9 9 6 ) . M u ltifidus r e co ve ry is n o t fo l l o w i n g reso l u t i o n o f
York: for
BC: Del ta Orthopaedic
P hysio thera py C l i n ic.
Lee. D.G . a nd
V leem i n g . A . ( 1 9 9 8 ) .
a u tomatic
lm pa ire d load transfer t h ro u g h the
a c u te fi rst e p i s o d e low b a c k pa i n .
pel v i c g i rd l e : a new model of a l tered
2 1 . 2 7 6 3-2 7 6 9 . D.G. ( 1 9 9 3 ) . Biomec h anics o f the thorax : a c l i n ic a l model of in v i vo fu ncti o n . } o u rna l of Ma n u a l a n d
Spine.
Lee.
Ma n i p u l a tive Th era py. 1 . 1 3 -2 1 .
D. C. ( 1 9 9 4 ,, ) . Bi o m e c h a n i c s o f the t h o ra x . I n P hys i c a l T h e r a py o f the
Lee.
n e u t r a l zone fu n c t i o n .
In
Procee d i n g s
from the T h i rd I n te rd i s c i pl i n a ry Wo rld Congress on
Low Rack and 1 9 9 8 . Vien n a ,
Pel v i c Pa i n . N ovember
Austria . R ic h a rd son .
C . . J u l l . C . . Hod ges . I' anJ
Hides . J . ( 1 9 9 '1 ) . Therape u t i c exercise
Copyrighted Material
for spi n a l segme nta l s t a b i l iza t i on in low b a c k pa i n . Ed i n b u rg h : Churc h i l l Li v i n gstone. V l eemi n g . 1\ . . S toeckart. R .. Vo l kers. A . C . W. and Sn ijders. C.}. ( 1 9 9 0a) . Rela t i o n between form a n cl fu n c t i o n in the sacro i l ia c j oi n t . ] : C l i n ic a l a n a tom i c a l a s pects. S p i n e . ] 5 . 1 3 0-- 1 3 2 . Vleem i ng. A . . Vol kers . A . C . W. . S n i j ders .
C.}. a n d S(oeckiJrt. R.
( 1 9 9 0 b ) . Re l a t i o n bet ween form
a nd fu n c t i o n i n t h e sacro i l ia c j o i n t . 2 : R iomcc h a n i c a l aspects. S p i n e . 1 5 . 1 3 3- 1 3 0 .
Bilateral shoulder pain in a 16-year-old long-distance •
sWimmer Mary Magarey
�
SUBJECTIVE EXAMINATION
Sally is a 16-year-old school girl u n dertaking her final year of schooling at an exclusive coed ucational pri vate school. She is from a family of t h ree children and one adopted daughter. Her father is a doctor and her mother a teacher at the same school attended by Sal ly
.
She is a high achiever academica lly and appears a we ll adj usted if q u iet girl. She is a lso a high level dis -
.
.
-
tance swimmer. with freesty le and butterOy her main events. At 14 yea rs of age. she was a national level swimmer but had not been able to achieve this stand ard for the last 2 years because of difficulties with shoulder pain. She came to me on the recommenda tion from the physiotherapist mother of one of her II
swimming contemporaries.
History Sally's presenting problem was one of bilateral shoul der pain. as indicated on the body chart (Fig. 11.1). worse on the left. t hough the side dominance varied [rom time to time for no apparent reason. She had the
pain in both shoulders whenever she swam and developed an ache in the same areas after swimming. This ach e lasted for 2 to 3 hours after swimming and her shoulders generally felt 'sore' at all times when she was in peak swim training. Her worst pain was with butterOy, on both recovery and mid p ull -through aspects of the stroke. She also had similar pain with freestyle
,
particularly at the catch and mid puIl
Fig. 11.1
Body chart demonstrating Sally's presenting
pain picture. The pain was intermittent with swimming with the ache in the same area after swimming. There was no
through, t houg h the level of pain was lower. The pain
pain in the cervical or thoracic areas, arms or hands. There
was present as soon as she started swimming. was not
were no pins and needles in the hands or feet.
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161
CLI N I C A L R E A S O N I N G I N ACT I O N: C A S E ST U DI ES F RO M EXP E RT MANUAL T H E RAP I S T S
the
sufficient t o prevent her from swimming, but inhibited
training. Her left shoulder pain, in
full training and progressively worsened through
a
the right, began some time later with no apparent
training session. She had no specific pain or difficul
specific precipitating incident. Since then, both had
ties with other activities but did not play other sports
followed the pattern described above.
that would put the same load or challenge on her
same area as
with Sally's a 'shoulder s\'limmer'.
We discussed swimming technique,
shoulders. At the time I first saw her it was the end of
mother indicating that Sally was
the summer swimming season, during which she had
getting little erfect in her stroke from her kick. I explained
been swimming for eight 2 hour sessions every week
how improving body roll and kick power could decrease
with a predominance of training in freestyle. She had
the load on her shoulders cmd, therefore, might reduce
just started
a
1
month lay-ofr from training before
beginning a slightly lighter load through the winter. Sleeping was no problem, even lying on her
and she had no morning stiffness. She took no anti-inflammatory or pain medication. Sally was in good general health and appeared to have no other
side.
identinable problems. Investigations included plain
the pain associated with her swimming, even though the kick is not as significant swimming as
it is of
a
component of distance
sprints (Maglischo.
1993).
We dis
cussed the possibility of working on these aspects of her stroke with her coach, in adclition to whatever specitlc problems were identified in her shoulders. Her mother,
who
did most of the talking
at
most
radiographs, diagnostic ultrasound and computed
visits, told a saga of attendance at multiple health
tomography
professionals in an attempt to lind a diagnosis for and
(CT)
arthrography;
none of
which
demonstrated any abnormality.
Several
resolution of Sally's shoulder pain.
years earlier, when Sally was training for
est to me
was
Of particular inter
the information that she had attended
the national swimming championships, she lifted a
live clifferent physiotherapists, none of whom, in Sally's
heavy suitcase and felt something 'pull' in her right
or her mother's opinion, appeared to have given satis
shoulder with immediate pain in the anterior sub
factory treatment. I found this information quite
acromial/superior capsular area. This pain was not
dauntingl The
severe but did not go
Table 11.1
away,
disrupting her swimming
sequence
agement is given in Table
of investigations and man
11.1.
Previous professional consultations before presentation
PhYSiotherapist 1 Orthopaedic surgeon
Treatment provided was ultrasound and interferential. with no benefit Ordered plain radiograph. ultrasonography and computed tomographic arthrography, all of which were negative. He injected what appeared to have been her subacromial space. with no relief of symptoms. even temporarily. He was not prepared to offer arthroscopic investigation because of her age and lack of findings on the diagnostic imaging
Physiotherapist 2
This physiotherapist worked in a sports specific physiotherapy clinic and had many years of experience with national level sports teams. Treatment prOVided included further electrotherapy and some basic rotator cuff exercises, again with no benefit
Sports physician
He indicated that she had sloppy shoulders and that she needed an exercise programme directed at her shoulders. He referred her to physiotherapist 3
Physiotherapist 3
T his physiotherapist had considerable experience in treatment of postoperative shoulders and worked in a sports-specific clinic. She was also experienced with national level sports teams. Treatment provided was shoulder and scapular stabilizing exercises (as far as could be ascertained from the description). Sally worked at the exercises but became disillusioned when the physiotherapist would not allow her to get back in the water to swim. It appeared that Sally probably did not give this programme a fair trial before looking elsewhere for assistance. Her mother's comment was 'It is hard to fit all that exercising in and swim and do homework'.
Physiotherapist 4
T his physiotherapist was a national level swim coach who had practised more as a swim coach than a physiotherapist. but who had specialist knowledge of swimming requirements and a depth of understanding of the psychological issues related to working with swimmers.
L
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11 B I LAT E RAL SHOUL D E R PA I N I N A 16-YEAR-OLD L O N G- D I STA N C E SWI M M E R
Table 11.1
Previ ous professional consultations before presentat i on I n parti cular he understood how important it is for swimmers to be able to stay in the ,
water during any rehabilitation. Treatment provi d ed included further exercises and stretchi ng with an emphasis on medial rotation of the shoulder. My und er stan d ing was that neither Sally nor her mother got on with this physi otherapist and the decision to cease treatment was based more on this than any failure of the treatment regimen. Chir opra ctor
No specific details of the chiropra ctic treatment were elicited, except that the chiroprac tor told Sally to 'swim through it'.
Phy s iotherapist 5
T his physiotherapist was also a sports orie nted physiotherapist with extensive national and -
inte rnatio nal team experience. T he comment from Sally's mother was that this was 'going down the same old path' and they did not persi st with her. General practitioner
This general practition er had an interest in na tural medicine and gave Sal ly eight inje ctio ns of glucose over a period of some months. This treatment appeared to help Sa ll y more than any other, although Sa ll y s mother was unable to explain to me the theo retical basis of pain '
relief related to glucose injections. T he benefit of these injections lasted approximately 12 months but she had not returned for further therapy when the shoulder pain returned ,
� IJ D
.
R E A S O N I N G D I SCUS S I O N A N D CL I N I CAL R E A S O N I N G CO M M E N TA RY
Based on the initial information regarding the
The bilaterality of her pain. while common with a sport that involves bilateral load on the shoulders,
patient's personal profile, her presenting
could also be
as well as the history of onset for the symptoms
impairment, while the anxiety created in an elite
in both shoulders, what were your hypotheses
athlete by impairment that prevents participation in
a
reJlection of
a neural processing
symptoms, general health and investigations
at that stage regarding dominant pain
the chosen sport could contribute to the presence of
mechanisms, possible sources and contributing
an affective component to her problem. The apparent dominance of her mother in the
factors for the symptoms and activity/ participation restrictions she was experiencing
interview situation also raised questions about Sally's
in her two shoulders?
ability to mal<e decisions for herself or speak her own
• Clinician's answe r
responsibility for her symptoms and their manage
mind. with the inherent potential of
not taking
ment. I also wondered whether her mother's level of
Dominant pain mechanisms
involvement in telling the story indicated that she was
The dominant pain mechanism I considered with
the driving force behind Sally's continued pursuit of
this girl was an input nociceptive mechanism. My rea
a swimming career. rather than Sally herself. This
soning for that related to the very mechanical nature
thought may seem a bit harsh, but this is a common
of her symptoms with the on/off features related to
scenario in individual sports such as swimming and
If this were the case. it would be likely to
her swimming and the localized site of symptoms.
athletics.
However, there were elements of her presentation that
have a Significant inJluence on Sally's motivation
made me also consider other mechanisms. For exam
Cor
ple. while the history of onset of the right shoulder
suggested.
compliance
with
any
management
strategy
pain sounds mechanical and. therefore, supports a
Sally's family situation seemed financially secure.
nociceptive disorder. the onset of similar pain in the
settled and happy. but the older adopted sister was a
left shoulder without a provoking incident could indi
high-level sprinter. so there was the possibility of
cate the presence of some central sensitization of her
Sally feeling that she needed to achieve to keep up
symptoms. There were also a
number of features that
could have supported this hypothesis.
with this older family member, again with potential inJluence on the outcome of any management.
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CLIN I CAL R EASON I N G I N ACTION : CASE S TU DIES FROM EXPERT MAN UAL THERAPISTS
Sally was also in her last year at school. a high aca
However, with an understanding of the load placed
demic achiever who indicated that she was keen to try
on both shoulders 'with swimming, particularly with
to study medicine on leaving school. This goal would
butterfly, I considered it more likely that her problem
obviously create significant pressure to achieve aca
related to similar mechanisms in both shoulders
demically, possibly altering the perspective with which
rather than somatic referral from a spinal source.
swimming was seen from that of earlier years. These features raised the question about whether Sally was using her shoulder pain as an excuse to back away from swimming without seeming to be giving up or failing to achieve in the same way as the older sister. However, a typical feature of high-level junior swimmers is hypermobility of the glenohumeraljoints coupled with altered muscle balance and control around the shoulder girdle in particular (Pink et aI., 1993; Scovazzo et al.. 1991). The history of a traction injury to the right shoulder as the original provoking incident seemed to fit a nociceptive presentation, with the likelihood that the other shoulder became painful as a result of Sally adapting her swim technique to try to avoid pain in the right shoulder. With the likely underlying hypermobility in both shoulders and the high load generated by swimming, particularly butter fly in which symmetry of stroke is essential. such a scenario seemed reasonable. With the advent of pain, muscle function around the shoulder girdle, and in particular in the rotator cuff. is likely to have been affected, such that an imbalance already present from the involvement in swimming would be accentuated. Therefore, while the potential for central sensitization and an affective component to be features of the pre sentation was definitely there, my favoured hypothesis
C o n tributin g factors As indicated above , I considered it highly likely that Sally had a strong contributing component of poor dynamic control of her shoulders. The particular fea tures of her story that support this hypothesis are the history of the pain associated speCifically with a sport that involves large repetition of the same action undertaken almost daily, with little chance. therefore. for recovery, added to little involvement in alternative physical activity and coupled with the stress of final year schooling. Knowledge of the loads required of the joints and muscles in swimming also led to support of this hypothesis and recognition of what is. in fact, a very common clinical pattern in high-level swimmers. Therefore, the reasoning supporting my hypotheses was based in part on Sally's particular presentation but also on my underlying recognition of the particu lar clinical pattern.
lEI
What were your thoughts after obtaining the histor y of previous management? Specifically what hypothesis categories were most informed by this add itional in formation and in what way !
at this stage was one related to altered motor output, with her pain perpetuated by excessive load on struc tures not adequately stabilized to cope with it. Poor
• C l i n i c ian's answer
muscle control and dynamic support of her shoul
I had a number of thoughts about the history of pre
ders and shoulder girdles seemed most likely to be a
vious management. Initially, I was disappointed to
dominant feature of her presentation.
hear what appeared to be tale of mismanagement of an elite athlete, even by health practitioners attuned to the needs of such patients. It also reinforced for
Sources of pai n
me the importance of understanding a patient's sport
M y main hypothesis about the source of Sally's shoul
and the particular needs of athletes within that sport.
der pain was the capsule of the glenohumeral jOint,
and relating management to those needs as much as
with the possibility of involvement of the superior
is reasonable. Even if it is not possible to relate man
labral structures adjacent to the biceps anchor and of
agement to the specific requirements of a particular
the biceps tendon itselJ. I also considered the rotator
sport. at least demonstrating an understanding of the
cuff as a possible contributing source of her symp
needs of the athlete and providing reasons for a par
toms. The bilaterality of symptoms meant that I
ticular management goes a long way to addressing
had to consider the cervical and thoracic spine as a
the cognitive/affective components of
potential source , with somatic referral to the shoulders.
establishing this history in such detail. I was also
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a
problem. In
11 BILATERAL SHOULDER PA I N I N A 16- Y EAR-OLD LON G-DISTA N CE SWIMMER
trying to flnd out whether the approach to treatment
ti ci pa ted would be effec t iv e had been tried in the past. because if it had the chance of success from my management was l ower. that I
an
Did you judge the mother's apparent dominance of the interview to be simply
trad itional approaches to s at is fy this family's needs, even tho u g h that was the b ackg rou nd from which t h ey c a m e . These considerations highlighted to me how imp o r tan t it was to provide a rational e xpla na t i on for my suggestions for management if I was to have any success in con vi nci n g them of its p o te n ti a l val ue.
typical of a parent or could this a n d their apparent understa nding and beliefs about what was required to rehabilitate Sally's
• Cl inical
shoulders be seen as potential contributing factors to her lack of success to date a n d something that would have t o b e addressed?
In discussing hyp othe ses at pre sentation regar din g
dominant
pain mechanisms. poss ible sources and
contributing factors lor the symptoms and ac tivity/
• C l i n i cian's an swer
participation restrictions. the clinician illustrates her
This question is somewhat diCl1cult to answer, a s the p ar ent who i s supportive and tuned into th e needs of an a do le sc ent athlete s howi n g considerable poten tiet! will t e n d to do an y t h i n g to help them to succeed . Such pe ople . as a t h l e te s themselves ofte n do. tend to want a quick answer to a problem and will 'shop around' in the h ope of IIndin g one. Therefore. S al ly 's mother could be viewed in this light a nd , at the time. t h is was my m ain interpretation of her motives. However. so-called 'pushy' parents are commonly seen associated with i n divi d ua l sports such as swimming and this image did come to mind somewhat. particu larly listening to her description of the list of attempts to lInd an answer to Sally s problems. My hypo theses, ou t li n ed in the answer to Q ues t i on 1 about S a lly's mother's influence on prognosis in p ar ticul ar, contin ue d t h r oug h this part of the inter v i e w. The comment about difficulty fi tti ng in the exercise w it h s t u dyi n g and s w imm ing did make me question their commit ment to success of a managemen t programme. I d i d find it in teresting that this fa m i ly had aban doned traditional pathways in th e i r attempts to solve Sally's pr o blems . with their use of a ch i ro practor. a l t ho u gh this sounded like it was short lived. and the apparent success of glucose injections despite their inabilit y to explain the hy pothesized mechanisms by which glucose injections would help painful shoul ders in an adolescent swimmer. Clearly, the injections had been ben eficial. but what surpr is ed me was that neither mother nor dau ghter had any idea of the pro posed mechanism of their effect. The fact that use of the chiroprac tor an d a somewhat alternative method of management of musculoskeletal disorders were sought late in the pie c e suggests a fa ilure of the more '
reaso n i n g co mme ntary
thinki n g on mu ltip le levels. Wh il e her thinking has occurred now in hinds ig h t in resp o n se to the specillc question asked. expert clinicians are also ab l e to think in this manner as they work through an exam in atio n The c 1inician s answers her e also reflect a hypothesis-oriented abil i ty to re cog n ize a broad range of diagnostic issues, i ncluding pain mech anisms. sources and physical c ont ri but ing factors. in addition to psychosocial fe atures in the patien t's presentation. incl udi ng her rela ti on ship with her mot her The hypo t heses considered are not closed at .
'
.
this early stage; rather they
are
clearly informed by
c onsi de ra b le experience with sho ulder prob le ms and prov ide an initial picture against which subsequen t information will be considered. Understanding a patient's tmderstanding the patient.
The
problem
requires
clinician's think
ing goes well beyond analysi s of s hou l d e r impair ment. with ser iou s consideration also give n
to this
pa tien t s personal context. including the specific '
needs of h er sport and the relationship she has with her mother. While the likely n e ed for act i ve management has been hypothesized. the impor tance of teachin g (e. g. ex plan a t i o n ) in this patient's management is also emphasized. that is not Simply teaching to do (Le. instrumental le ar n ing) but t e aching to promote altered understand ing and fe e l i n g s (Le. tr ansformat ive learn in g). This level of teaching must be ba sed on ass essme n t of the patie nt's (and in this case the m o ther s ) under s t an ding and feelings, in cl ud ing the basis of those thoug h t s and emotions (Le. pr e vious advice. past medical experiences. pe r s o n al goals and pres s ur es) Expert clinicians must be ex pert teachers. '
.
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C LI N I C A L REASO N I N G I N ACTI O N : CASE STU D I ES F RO M EXP E RT MANUAL THE RAP I STS
tEl
PH YS I CA L EXA M I N AT I O N
For the physical examination, Sally u n dressed to her swimsuit. Observation demonstrated the broad shoulder. narrow hip posture typical of an elite swim mer, with very horizontal shoulder girdle, wid ely pl aced scapulae and sli ghtly m edia ll y rotated shoul ders. There was no apparent asymmetry i n her shoul d er girdle posture or muscle development. Her upper quarter musc le d evel opm en t was n o t outstanding. Spinal posture a ci c
re ve al ed
a slight ly ex agg er ated th or
ky p hosis and lumbar lordosis. also typical of
swimmers, and the tone in her abdominal muscles. gluteal muscles and legs appea red go od .
Furthe r tests Isometric rolator Cliff test s.
There
was no pain but
the impreSSion of poor power, particularly in lat eral rotation. Specillc t ests for long head of biceps in different positions were negative. Active movements of the cervical and thoracic spine
.
This was generally mob i le to hyp er mobi l e with no pain loca lly or in the shou Iders. Neural provocation tests of the upper limbs.
No
ab n ormali ties were detected in the upper limb ten sion tests l. 2B or 3
( B utler, 2000). Test 2A
was
not carried out as I co nsi der ed that any ab n orm al ity in the median nerve component of the neural
and
Glenohumeral joint flexion and abduction.
glenohumeral j oi nts were
The
hype rmobile an d there
was excessive s capul ar rotation. There was no pain
any ab nor m alit y related to sc a pul a r depres
sion and protraction would h ave been obvious with test 2B. Glenohumeral joint stability tests.
The mobility
rating scale used to evaluate shoulder translation
at end-range nor with overpressure. Glenohumeral joint medial rotation, measured in
There was normal
abduction and full flexion.
with test 1
structures would have been detected
Active shoulder moveme nts
tests is similar to that used for measurement of mobility with
a
La ch ma n
'
s
test for the anterior
range in b oth shoulders in both positions, with
cruciate ligament. (Normal mobility is rated as
some slight discomfort on overpressure to medial
zero. with three measures of increa sed laxity: +.
rotation in full ll ex i on . This position was tested as i t is
a
as
slightly
increased
m oderat ely
translation ; + +.
translatio n;
and + + +.
markedly
movement emph asiz ed b y swimming coaches
increased
important
in cr eased translation, to subluxation. This rati n g
for
obtaining
maximum
power
during the catch phase of the freestyle or b utterlly st r oke . Glenohumeral joint lateral rotation measured in abduction and full flexion.
There was a sligh tly
scale is used by l ocal orthopaedic surgeons and phy siother a pi sts
but has not been validated.) Using
this rating scale, the anterior drawer was hyper mobile (+)
w ith
right greater than left. Posterior
increased range com pa red with what might be
dr awer was hy per m ob il e (+ +)
expected as normal, with a 'loose' end-feel. No
than right. The inferior and anteroinferior glid e
symptoms.
was slightly hypermobil e on both sides. No appre
Hand behind bac/(.
In t h i s posture, there was nor
mal mobility of both shoulders, com b i ned with excessive winging of the medial border of the scapulae. Stabilizat ion of the scapulae did restrict
w ith left greater
hension or pain with any s tabi li ty test. All tests had a s l i g h tly loose end-feel Passive physiological and accessory movements of the glenohumeral joint.
All movements were
glenohumeral jOint range; however, it could still be
hypermobile with a loose end-feel. Quadrant
considered within nor mal limits.
positi o n , on the low side of the quadrant, repro
Horizontal flexion and extension.
Gen eral l y hyper
mobile, with no re p roduc tion of symptoms. With all
active
physiological
movements,
excessive
duced Sal ly s pain on b oth shoulders. Differ enti al '
testing in that position demonstrated increased pain
with
subacromial
di st rac t ion
.
decreased
movement of the scapulae was evident, with poor
pain on subacromial compression and a slight
stabilization of the medial border so that arm
increase on glenohum e ral compression, indicat
m ovem ent was accompanied by sc apula r medial border winging.
ing a p robab le c apsular source to her pai n with a possible slight con tri b uti on
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from something
11 BI LAT ERAL SHOULDE R PAIN IN A 16-YEAR-OLD LON G-DI S TA N CE SWIM MER
Fig.1 1.2
Dynamic rotar y stabi lity test d e monstrated in
the catch position of the freesty l e stroke. the position in which Sal ly's symptoms were most evi d ent (Magarey and Jones.2003a).
Fig. 1 1.3
Rotator cuff dyna m i c relocation test
(Magarey and Jones. 2003b).
(Magarey
intra-articular
and
Jones.
1991:
Maitland. 1991).
90 degrees of flexion. abduction or scaption. with
Passive movements of the scapulot/lOracic joint. All movemen ts were hypermob ile with a loose end feel. with a particularly mobile scapular abduction and lateral tilt ( winging ).
quite marked weakness in these positions.
Rotator cuff dynamic relocation (concavity compres sion) test. This test is shown in F igure 11.3 (Jones and Magarey. 2001; Magarey and Jones .
Passive movements of the acromioclavicular and
20m a . b) . With the arm in the plane of the scapula
All hypermobUe. particu
and approximately 60 degrees of abduction. Sally's
sternoclavicular joints.
larly posteroanterior glide on both acromioclavic
ability to generate a stabilizing co-contraction of
ular joints and posteroanterior glide on the left
the rotator cuff was very poor. With considerable
sternoclavicular Palpation.
No
jOint.
specific
facilitation. she was eventu ally able to achieve it. areas
of
tenderness
or
a ltered tissue texture could be found. In particular.
but with poor-quality contraction.
Side-lying scapular proprioceptive neuromuscular
long head of biceps. supraspina tus insertion. the
facilitation (PNF) diagonals.
subacromial and subcoracoid spaces and the pos
position of the scapula
terior joint lines were clear.
of the scapula in the four diagonals, even follow ing
Dynamic rotary stability test.
This test is shown in
and
Aw a reness of the
di fficul ty in movement
facilitation. was tested (Magarey and J ones . 2003a)
Figure 1 1. 2 Uones and Magarey. 2001: Mag arey cmd
(Fig.
Jones. 2003a.b). No shifting of the humeral head
four corner positi ons (up and forward s . down and
could be detected during testing in any position. but
back. up and back. down and forwards) against
there was poor quality of contr a ction of both medial
any resistance was poor. particularly down and
and lateral rotalors. par ticularly in positions above
back. which is predominantly lower trapezius
11.4).
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Sally's abi lity to maintain any of the
CLI N I C A L REAS O N I N G I N ACTIO N: CASE STUDIES F RO M E X P E RT M A N UAL THERAPISTS
contraction. In the up and forwards movement. she had a tendency to go into forward movement of the shoulder girdle rather than upwards. with this forwards movement representing a protraction and anterior tilt of the scapula with
a
lack of the
elevation component. While this movement was not ideal, it was not as signilkant as the lack of down and back movement. I chose to omit examination of
accessor y move
ments of the cervical or thoracic spine on Day 1 because I wanted time to assess dynamic stabilization of the glenohumeral joint and Lhe scapul a on the Fig.11.4
Scapular proprioceptive neuromuscular
chest wall.
facilitation pattern of'down and back'-the direction in which Sally's awareness and control was found to be particularly poor.
� I J -
o
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
Please h ighlight h ow the i n formation from the
Sources of symptoms and contributing
p hysi cal examinati on d i d or di d not support
factors
your previous hypoth eses rega rdi ng dom i n a n t pa i n mech a n i sms, source of the sym p tom s and contri b u ting factors?
The only physical test that reproduced Sally's pain was the
glenohumeral
quadrant
test
(Maitland,
1991). The quadrant is not a test that identil1es spe cific structures at fault. but it does appear to be a sen
• Clinician's answer
sitive clinical test for detecting abnormalities around the shoulder complex. The details of how to under
Pain mechanisms
take this testing can be found in Maitland (1991).
My physical findings supported my primary hypoth
Further discrimination of source can be made with
esis of an input nociceptive problem coupled with an
the differential testing described above. Differential
impaired outpu� motor mechanism. The support for
testing involves altering the stress on structures
this hypot hesis was partly the lack of findings that
within the subacromial space. the glenohumeral jOint
would support any other mechanisms. Sally demon
capsular structures. intra-articular sLructures and
strated none of the physical features that tend to be
the acromioclavicular joint. The responses to such
identified with centralization: for example, hyperalge
testing with Sally indicated positive responses for a
sia, inconsistencies in response to physical testing, and
glenohumeral capsular source to her symptoms, with
spontaneous pain. Also, she showed no features that
her pain exacerbated by increasing the stretch on the
readily supported the possible affective component
capsule with the shoulder in the provocative quad
that had been hypothesized during the subjective
rant position (subacromial distraction) and decreased
examination, with Sally cooperating fully and openly
when the stretch was reduced (subacromial compres
with all aspects of the physical examination. Her
sion). Extrapolation from anatomical and biome
responses to physical tests were consistent and she did
chanical analysis related to restraints to movement
not display an obvious fear-avoidance or inappropri
would indicate the rotator interval/coracohumeral
ateness in her responses. The mechanical nature of
ligament region as the strucLures most likely to be
any symptoms found and the poor muscle control of
responsible for this pain. There was also weak support
her glenohumeral joint and scapulothoracic articula
from differential testing for an intra-articular compon
tion also supported my primar y hypothesis.
ent to the pain (there was some slight increase in her
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1 1 B I LAT E RA L S H O U L D E R PA I N I N A 1 6- YEAR- O L D L O N G - D I STA N C E SWI M M E R
symptoms with t he a d d i ti o n o f glen ohu mera l com press i o n to the qu a d r an t position ) , in th is case, prob ably superior l a bral in o ri g i n , T h erefo re
,
• C l i n i cal
reaso n i n g c o m m entary
The hypoth e s i s te s ti n g for p hy s ica l impa i rments
m y hypothesis related t o t h e gleno
and
a ss o c i ated
sources that was ini ti a ted in the
h u meral j Oint as the primary source of symptoms, with
subjective ex a m i n a tion is continued through the
the superior c a psular and lab ral structures assoc i a ted
physical ex a mi na ti o n
with the b iceps anc hor as the most l ikely so urce, was
does not sim ply follow a predetermined series of
,
Importantly. the cl i n ic i a n
supported by the p hysical findings, The hy permobility
sh o uld er
of the whole shou lder gird le also su ppo r te d my hypo th
di rec tly related to earl ier hypotheses generated and
assessments; rather tests chosen are
esis, The fact that the fi ndin gs rela ted to pa in provoca
the patient's particular presentation . The depth of
tion were m i n ima l a lso su ppo rted my hypothesis that
the cl i nici a n s physical examination is a ppa re n t in
th ere was little or n o intri nsic pa tho l ogy with t h e p a i n
her assessme n t of muscle fu n c tion , which incorpo
primarily r e la ted to irritation o f these str uctures as a
rated important aspects such as patient a wa re ne s s
,
resu l t of poor muscle c on trol of the hy permob i l i ty, Lack o f fi n d i ngs rel a ted to the neural provocation
'
and timing of activa ti o n assessed thro u g h a c o m .
b i n ation of functionally relevant proc ed ures
tests an d normal a ctive mo b il i ty of the cervical and
a pp a rent
A l so
,
in the clin icia n s reason i n g is he r '
thoracic spi ne negated these structures as sources,
open mindedness with reg a rd to the hypotheses
altho u g h I recognized that this could not be com
con sid ered , A common error in cl i ni c a l reason i n g
p letely e l i m i n a ted from my th inking as the examina
is
tion of the spine was not complete.
re cog n i ti o n i s the d i ffic ul ty c l i n icians have in t r ul y
The hy po th esi s rel a ted to c o n tri b u ti n g fa ctors of
b i as
,
a n d t h e g r e a t e st hindra nce t o pattern
hypo th es e s e nt er t a i n s a n um
conSideri n g a n d d i s pr o v in g co m petin g
poor muscle c o n trol was s tron gly s u ppor ted by the
( see Ch . 2 6 ) . Here the clinician
p hys i c a l fi nd i n gs o f lack of dy n a m ic c o n trol o f the
ber o f d i ffere n t hypotheses , noting th ose that are
glen o h u meral j o i n t and sc ap u l o thor a cic
su pp ort e d and those that are n o t s u p po r t ed by the
duri n g d y n a m i c a n d fu nctio n a l testi ng
a r t ic u l a t i on
phys i c a l ex a mi n a t i on ,
.
E);f'rf'49··i§·'• Treat m e n t
of t he deltopec toral muscles d u ring isokinetic rotation a t the glenohumeral j oi n t , and the s i g n i fic a nce of th e se research fmdin gs , par tic u larly for s w i m mers I .
1
ind ica ted to S a l ly a n d her mother wh at I fel t was the
It seemed to me at this stage that any success w i t h
most ap pro pri ate c o u rse of treatment I cou ld o ffer. I
Sa lly wo u l d rely a s mu c h as any t h i n g on gaining t h e
reali s e d
con fidence of both Sally and her mother, Therefore,
from what had been offered by other hea lth pro fes
I expl ain e d what I considered to be S a lly s prob lem,
Sionals in whom they d id not
'
that as this wa s n ot substa ntia l ly d i fferent
h ave co n fi dence , it was
ind ic ati ng th a t sh e h a d hy permob ile shou lders and
i mpor t a n t that this app r o ac h was so l d very s tron gly
sc apu l ae with i na d equ ate muscular con trol for the
to co n vi n ce them that it was not sim p ly 'more of the
demands she p l aced on them . The maj o r ity of her p a i n
same ' . It was also i mpor t a n t t h a t a ny reh a b i li ta t i o n
w a s likely t o be rel ated to genera lized l ow g r a d e capsu
prog ramme be a d a p ted to a regi men of swim tra i n i n g,
-
'
'
l a r inflammation from the conti n u a l ir ritation caused
as this was obv iou sly impor tan t to both S a l ly and my
by stress created by the high levels o f swimming.
c r e d ib ili ty I pO i n te d o u t that the next 4 weeks when
I bro u gh t the skeleton i nto the cu bicle and s howed
s h e was out of the water would be a n ideal time to
.
them where these structures were, t he reason why the
work hard on im p rov i n g her muscle functi on. Once
ro tator c u ff is wel l pos iti oned to fu nction as the pri
swi mmi ng recommenced,
mary g leno h u m era l j o int st a bilizer and what was hap
i n g coupled
pening with S al ly ' s scapulae when she loaded her
gramme through the wi n ter wou l d b e ad vanta geou s
s houlders. I t a l ked to them abou t core sta bili ty a nd the
ho pe fully putti n g her i n an opti m a l posi tion to re tu rn
find ings o f research u ndertaken by David et a \ .
( 2 000) ( 1 9 9 8 ) , d emo n strati n g consistent fir i n g
to fu ll training w i t h o u t p a i n in th e spri n g . I emph a
and Ca rr et a \ .
sized th a t the primary respo n sibi l i ty for th e pro
of the rotator c u lT a nd b iceps gro u p p r i o r to a c tiva t i on
a
g ran1ffi e wou l d rest with
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reduction in swim train
with ti me spent on her rehabilitation pro
S a l ly herself
and t h at
,
.
C LI N I C A L REASO N I N G I N ACT I O N : CAS E STU D I ES F R O M E X P E RT M A N UA L T H E RA P I STS
th erefore, S a Uy had to want to d o the programme for it to be success ful. I gave them the opportu n i ty to decide whether they wanted to try the prog ramme. Once they i ndicated that they did want to try, I spent some time teachi n g S ally rotator cuff activation with the d yn a mi c relocation m a noeuvre, so that before she left she was able to produce
a
relatively isolated rotator
c u lT co-contraction of both s h o ulders in thi s posi tion and hold it wh ile lifting and lowerin g her hand with her
arm in a supported position. I a lso ta u ght her simple scapul ar awareness strategies . with particular emphasis on scap u l ar d epression and retraction , as this move
Fig. 1 1 . 5
ment was the one identified as least e ffective. Since
on fi rst assessment.
S a l l y s scapu l a r co ntrol i n fou r- p o i n t k n e e l i ng '
S a lly was only able to m a i n t a i n the contraction with out l oading, these movements were u ndertaken wi th
when tested in s u p i n e . She was o n ly a b l e to m a i n t a i n
o u t ad ditional load . S he was encouraged to do these
t h e c o n tr a c t i o n a n d l i ft a n d lower o n e leg from crook
exercises at least once a day in a set exercise time and to
l y i ng. She was also ab le to maintain a TA c o ntraction
work on increasing awaren ess of shoulder and scapu
during brid g i n g with seg m e n t a l l i fti n g a nd lower i n g ;
l ar stabil ization with movement during the d ay. The
t hese two exerc ises were al so add ed t o the pro
a im o f this was to faci li ta t e activation of correct timing
g ramme. together w ith an ex p l a n ation o f how t h ey
of c ontraction i n these stabi lizers.
s ho u l d hel p her shoul der problem .
• Treat m e n t 2
• Treatm e n t 3
The next tre a tme n t took p l ace 1 week l a ter. At this
By t Ile third v i sit. S a ll y h ad m i n i m a l pain
t i me . S a l ly had been p a i n- free (she was not swim
side of the quadrant. She was able to m a i n tain a rotator
m i ng) a nd both her rotator c u ff and sc apu l a r retrac
c u ff dyn amic relocation contraction d u ri n g isol a ted
on
the low
tion con tractions were improved. The p a i n o n the low
glenohumeral j O i n t rota tions agai nst l i g h t theraband
s i d e o f t h e q u a d r a n t position was a lso less. She was
resistance i n approximate ly 100 deg rees of tlex i on .
able to
m a i n ta i n
the rotator c u ff contra c t i o n w h i l e
whi l e simultaneously mai ntaining
a
st able scapu l a .
l ift i n g her fo rearm o f f the s u p port. Awareness o f
Her abi l i ty t o stab i l ize her scapu l a i n fo u r-point kneel
s c a p u l a r p o s i t ion d u r i ng PNF p a t t e r n s w a s a li ttle
ing was a lso i mproved. so that maintain i n g this posi
improved . Importantly. i n review of the rati o n a l e fo r
tion d u ring PNF p attern m oveme n ts against theraband
t h i s a p p r o a c h to m a nageme n t . b o th Sal ly and her
resi sta nce with the oppos i te arm were included in her
mother appeared to h ave a good understa n d i n g o f
programme. Isolated l owe r trapezius exercises were
wha t wo u l d b e required and w hy. Assessment
of
scapular
control
replaced with fu nctional PNF scap u l ar diago n a l s also in
fo u r-p o i n t
against theraband . while m a in ta i n i n g the humera l
kneel i n g w a s u n d e r t a ke n . demons trati n g good ab i l i ty
head dynamic re location. A bdomi n al fu nction had
to i s o l a te scapu l a r protraction ( F i g . 1 1 . 5 ) but poor
improved considera bly. i n d icati n g that her poor contTol
e n d urance w h e n loaded by l i ft i n g one arm. d e mon
on first testi ng was likely to be a res u l t of poor motor
s trated by w i n g i n g of t h e med i a l border of the
awareness/programmin g rather than true weakness .
scap u l a . Assessment o f isometric l ower and middle
At this poi nt. TA contro l during ro tary leg move
trapezius fu nction revealed cons iderab l e weakness o f
ments in s u p i n e was assessed . as was glu tea l fu nction
lower trapeziu s . s u c h tha t she co u ld o n ly m a i n t a i n
a
on a stable TA contraction in prone. Appropriate
s t a b le scapula i n depression w i t h the arm supporte d
levels or exercise for both these fu nctions were a d d ed to
i n approx i m ately 1 2 0 deg rees glenohumer a l abduc
the prog ramme. I also described how to make an exer
tion and elbow flex i o n . In this positi o n . rotator cufr
cise bar to facilitate abdomi n a l fu nction with an exer
co-contraction a n d h u mera l l ateral rotation c o u ld b e
cise colloq u i a lly know n as ' twisties · . as described by
a c h i e ved . T h i s exerc ise was added to her progra m me.
Peter Blanch. physiotherapist to t he Aus tra l i an Swim
Transversus abdominis ( TA l fu nction was a ls o poor
team at the Austra l i a n Institute of Sport ( F i g . J 1 . 6 ) .
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1 1 B I LATE RAL S H O U L DER PAIN I N A 1 6 -YEA R - O L D L O N G - D I STA N CE SWI M ME R
Fig. 1 1 .6
Fig. 1 1 . 7
T h e ' a b d o m i na l /tw i s t i e s b a r ' fo r fac i l i tating
Wa r m - u p exerc i s e with t h e r a b a n d i n a
exte r n a l o b l i q u e con tracti o n and body ro l l i n swi m m e rs
s i m u lated catch pOSition fo r t h e b u tte rfly stroke, in w h i c h
with s h o u l d e r p a i n . T h e twisties ba r consists of a b ro o m
S a l ly worked on s ett i ng the s c a p u l a e i n a n e u t r a l sta b l e
h a n d l e o f a p p ro x i mately 1 80 e m l e ngth, w i th b o l ts a n d r i ngs
pos i t i o n , relocating t h e head of h u m e r u s i n the g l e n O i d
at each e n d , each fa c i ng in o p p o s i te d i re c t i o n s . T h e ratu bing
a n d m a i n ta i n i ng c o n trol o f both w h i l e p u l l i n g aga i n s t t h e
of a p p ro p r iate stre ngth i s th e n atta c h e d to the b o l ts and
t h e ratu b i n g i n to t h e downsweep p a r t of the stroke.
co n n e c ted to s i m i l a r bolts o n the w a l l , s o that o n e i s p u l l i n g at r i g h t a n g l e s to the body p o s i t i o n b e h i n d the pati e n t and t h e other i n the s a m e d i re c t i o n fro m i n fro n t
Sa l ly three specific pr etr a i ning exerc i s e s : o n e aimed at
o f th e patient, t h u s p rov i d i n g a rotary res i s ta n c e . T h e
facilitat i ng rotator cufl' co-contraction d u r i n g swim
pati e n t c a n t h e n l i n e th e i r t r u n k u p s o t h a t the resista n c e
ming. the second at facilitat i n g the combination of
wo rk i s p e rformed fro m neutral towa rds i n n e r r a n g e o r
rota tor cuff co-contraction a n d sc a p ul a r control
fro m outer r a n g e towards m i d - range. Fo r s w i m m e r s , the
( F i g . 1 1 . 7) and the third at enc o u ra g i n g S a lly to lead
parti c u l a r benefit of this exe rcise i s that they can l e a r n to i n i tiate the rotation fro m th e p e l v i s a n d t h e n i n tegrate the t r u n k m ove m e n t, t h u s m i m i c k i ng the action req u i red a t
her body roll from the hips by u sing her o b l i q u e abdomin al m u s c l e s , fa ci l i t at i ng a stretch-shorteni ng contraction in these m u scles and thus redu ci ng the
the catch p h a s e of t h e sw i m s t r o k e . M o re c h a l l e n g i ng
l o a d on her s h o u lders . I checked the remainder of the
rotational load can be p ro v i d e d spec ifica l l y fo r swi m m e rs with t h e bar ove rhead . M ov e m e n t is s ti l l i n i tiated fro m
exercise progra mme and modified it a p propri a tely. We
the p e l v i s , b u t the longer lever p rovided by h av i ng the b a r
decided to review the s i tu ation in 2 w e e k s to evaluate
ove rhead p rovides m o re c h a l l enge t o th e a b d o m i n a l s i n a
the effect of these s pecific pretr a i ning exercises on her
p o s i t i o n s i m i l a r to t h a t re q u i red at t h e catch phase, a l b e i t
return to s w i mmin g .
w i t h both a r m s ove r h ead not o n e .
A t t h i s point, r decided t h a t I should try t o m ake the programme more interesting for a 1 6 - year-old girl. I decided to try to incorporate some S w i s s b a ll
• Treatment 4 Fo lloWing this v i s i t
work and spen t some time working out ways in which 3 - week b reak in treatment was
I cou ld ad a pt her exercises to be done on the ba l l .
prov ide d . d u ri n g which time S a l ly began swimming
My m a i n aims at t h i s stage were to improve her
a
tra in i n g a g a i n . A t the next visi t , she indicated that
abdom i n a l a nd p elv ic/hip strength a nd control as
she had less t i m e for the exercises a nd that she still
q u ic kly a s pos si b le to tr y to reduce the load th r ough
had some pain during s w i m m i n g , but it seemed to be
her shou lders, wh i le conti n u i ng to work on her
less . She was on ly swim ming t hree mor nin g s a week
shou lder a n d sc a p u l a r stability, which I a n ticlpa ted
at t h i s stage. Her quadra nt assessment indicated
a
would take l o nger to i mprove, pa rticula rly si nce
s li g ht i ncrease in p a i n with the same d eg ree of resist
she was s w imming. Therefore, her abdom i n a l and
ance a pplie d to the movement. Assessment of abdom
pelvic work could be quickly progressed onto the ball
inal
a nd
gl u te al
fu nction demonstrated
marked
and the u pper q u a r ter exercises made more chal
imp rovement. whi le i m prov eme n t in s capu l a r a nd
lenging by d o i ng them on the unstable surface pro
ro tator cu rl' fu ncti on
v i ded by the b a l l . The i n t entio n was to do th is at the
was
l ess appa rent. As a resu l t of
the retu r n to the water. 1 spent some t i m e teac h i n g
next v i s i t .
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C L I N I C A L REAS O N I N G I N ACTI O N : C A S E STU D I ES F RO M E X P E RT M A N UAL T H E R A P I STS
• Treat m e nt
S
prog ramme cer t a i n ly seemed to h ave been effective.
At this next v i sit. S a l ly i n dicated t h a t s h e had done
fa irly
as S a l ly reported r ed uced pain with s w i m m i n g and
conscientiously.
more awareness of her scap u l ar posi tion and a sense
th o u g h u s u ally before she left home to go to the pool
o f control i n her s houlders. She was al so more a ware
the
pretra i n i n g
exercises
rather than a t the pool itsel f. a s much so that she d id
of her body rol l . t h ou g h could not see that it made
not st a n d out fro m the crowd as d i fficulty comple t i n g
much d i rference to the l o a d thro u g h her shou lders .
t h e m pools ide. W h i l e this w a s not i d e a l . the time
She was not swimming compe titively at this stage. so
d i fference was relatively small and I decided t ha t
a ny effect on her swim times by her concentration o n
t h e faci litation wo u l d probably sti l l be va l u able. The
t h e s e strategies c o u l d n o t ye t be deter m i n e d .
REASO N I N G D I SC U SS I O N A N D C L I N I C AL REASO N I N G C O M M E N TA RY From yo u r c o m m ents earlier a b o u t the
This perception had the potential to provide
i m p o rta n c e of gai n i ng t h e confi d e n c e of Sally and
positive outcome on the basis of placebo. I feel it is impor
degre e of
h e r m o t h e r a n d the t i m e yo u gave to exp l a i n i ng
tant to build on such advan tages. so that the time spen t
a
a n d ed ucating them on both the p ro b l e m a n d its
on explanation of the problem was in tended to reinforce
ma nageme nt, you c l e a r l y place a lot of em p h a s i s
the 'shou lder ( a n d swimm i n g ) exper t' perceptio n . This
o n e d u cati o n . C o u l d you c o m m e n t o n yo u r
also allowed me to present a potential programme to them that was n o t u n l i ke what they had been exposed
reaso n i ng b e h i n d this ?
to before w i t h o u t elic i t i n g an i mmed i a te ' more of the
• C l i n i cian's an swe r
same' reactio n . t h u s e n h a n C i n g com p l i a n ce
My dec i s i o n to spend a c o n s i dera ble amo u n t of time
impor tant for self-ma n ageme nt. If S a l ly could u n der
Patient u n d ersta n ding of
.
the problem
is
also
on explanation a n d e d u c ation was based o n the pri n
s t a n d t h a t swimm i n g wh i l e she had poor control of
c iple that p atient m a n a geme n t should be a shared
her scapul a r and gle n o h u meral hypermobility was
respon s i b i l i ty a n d that i t will be more s u ccessful if the
l ikely to exacerbate her symptoms , she was more
patient h a s been
l ikely to a g ree to a mod ified tra i n i ng prog ramme tha n
an
ac tive contri b u tor to the d eve lop
ment of the man agement p l a n This convic tion is s u p
if I had sim ply t o l d h e r s h e must stay o u t of t h e water.
ported by the observation that m a ny patients w i th
S i m i l arly. such understanding mea nt t h a t she was
chro n i c problems te l l stories of m a n agement imposed
highly motivated to i mprove her muscle control so
.
on them or management that they d o not fu lly under
that she could retu r n to s w i m m i n g as soon
stand. so that they feel they lose control of the situatio n .
sible. S a l ly was fa r less l ike l y to do someth i n g sil ly that
as
pos
Empowerment seems t o be a n impor t a n t component
wo u l d exacerbate the pro b l em if she understood the
to a ny s u ccessful m a n a ge me n t strategy. W i th S ally's
reasons why she should behave as s u gges te d
.
p articular s i t uatio n . I hypothesized that a lack of
Part of the proposed programme included increas
empower ment appeared to be one fa ctor that was
ing Sal ly ' s awareness of body roll and kick, with t he
common to mos t of the strategies attempted . It seemed
need to improve her strength and awareness of abdom
t h at nobody had ever explained to S a l ly or her mother
inal and pelvic m u scle fu nction ; this was in tended to
what the likely mec h a nism of symptom production
reduce the l oad on her shoulders. Without an adequ ate
was a n d . th erefore. why any par ticular approach to
u nderstanding of her problem and the mecha n.ics of
m a n agemen t should be und ertake n . If the therapists
swimming. it is u n l il<ely that S a l ly wou ld h ave seen the
had . in fact. exp l a i n ed these points . n e i ther S a l ly nor
pOint o f a progranlffi e a i med a t abdominal and gl u teal
her m o ther appeared to h ave grasped the concept.
strengthenin g and would not have compl ied with it.
I recognized that r h a d an i nitial advantage with Sally
A fu rther point that was i mpor tant to m a ke to S a l ly
and her mother as r h ad been recommended to them as
a n d her mo ther was t h a t a p ro g r a mme such as that
a 'shoulder expert' . so that they had come with
s u ggested had the pote n t i a l to slow S a l ly ' s race t i m e s
a
posi tive
perception of my abili ly-whether wel l founded or not !
.
at least i n the short ter m . w h i l e she was learning the
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1 1 B I LAT E R A L S H O U L D E R PA I N I N A 1 6 -YEA R - O L D L O N G - D I STA N C E SWI M M E R
stabi l ization s trategies i n the water. As with a ny new tec h n i q ue. its mastery t a ke s some time and perform a nce is usua l ly reduced d u r i n g the m a s tery p h ase. Sal ly had to be prepa red to accept t h i s a n d work through it. However. this was not an issue for S a l ly. as her times for the season j u s t completed had been s low anyway as a res u l t of the shou lder pain. The p o ten t i a l for improvement was s u fllcient t o ma ke her prepared to try the prog ramme. We also had the advantage that she had come to see me in the q u ieter seaso n . so that a short-term red u c tion in times w a s n o t as d i sastro us a s i t m i g h t h ave b e e n a t the b egi n n i ng o f a new seaso n .
fit wel l with the attri b u tes of ex p e r t manual therapi sts
described
by
Jensen et a l . ( 1 9 9 9 ) .
Reassess ment . a form o f hypothesis tes t i n g a n d
mediu m for rellection. a l s o features stron g ly i n the c l i n ician s man agement. Importantly. the reassess '
ments
here include patient u ndersta n d i n g as well as
physical joint a n d mu s c le
co n tr o l
it
great
d e al of emphasis on education and ex pla nation . yet their reassessments may only focus on physical signs. In C h apter 1 . teaching was presen ted as
a
focus of c l i n i c a l reasoning. If p a ti en t ( a n d sup porters) u nderst a n d i n g is judged to
• C l i n i cal
impai r m e nt s/
dysfullction s . M a n u a.l th e r a pi s t s often p l ace
be
a
potential
problem. as in this case. then reassessment of
reaso n i n g commentary
expla
n ation s provided is essen tial to ensure learning has
t hrough t h e c l i n i c i a n ' s man agemen t d escribed and
st ill j udged to be fau l ty. fu rt her exploration for the basis of t heir views (an importa n t step for some patien t s to revise their u nderstanding/beliefs) and/or al tered stra te
discussed above. These d i mensions of manageme nt
gies of explanation may be required .
occurre d . If their understanding was
Explan ation/teac h i ng. patien t u n derstanding ( cog
nitive and motor ) . empowerment, shared d e cis ion m a k i n g and sel f-man agement are all e vid e n t
Reassess m e n t of a l l dy na m ic features ind icated con tinued improvement. with the least i mprovemen t i n the rotator c u ff fu nction-predictable a s these are the muscles most i n h ibited by the shou lder p ai n . We trans ferred abdominal and lower limb work onto the SwiSS ball as pla n n e d . with Sally doi n g a series of exerc ises aimed
at
improv ing
her
abdominal
con trol
a nd
strength avai lable for kicking. One i nvol ved ma intain
i n g control of her tTu nk and pel vic position while b a l ancing on her thoracic s p i n e o n t h e b a ll. [n th i s posi tion she d id alte r n a te h i p flexion. fol lowed by knee exte n s i o n . trying to repl icate the muscle activi ty a nd movement
req uired
in
the
u p beat
of
her
kick
1 1 . 8 a ) . A second exercise u nder taken i n prone
( Fi g .
lnvolved Sal ly bal anCing through her hands. m a intain ing
a
stable glenoh umeral j oint an d scapula. with the
ball u nder her abd omen . From this position, with her toes assisting the b a lance, S a lly maintained
a
TA con
traction while a lternately lifting one leg from the hip s . ensuring t h a t s h e used predomi n a n tly gl u te a l s t o per form this action ( F i g . 11 . 8 b) . As her ba lance improved
Fig. 1 1 . 8
Faci l i tated k i c k i ng fu nction on a Swiss ball
while m a i n ta i n i ng abd o m i n a l contro l . (a) In supine over the ball, Sally was req u i red to m a i nta i n h e r b a l a n c e t h rough o n e l eg a n d her tru n k, e n s u ring a p p ropri ate a b d o m i n a l and g l u teal activati o n w h i l e go ing t h rough the kicking motion with the othe r l eg, trying to rep l i cate the u p b eat action of the k i c k . (b) In p rone ove r the bal l . Sal l y was req u i red to m a i n ta i n an appropriate abdom i n a l contraction a n d
with both these exercises. S o l ly increased the rate of t h e
ba l a n c e , assi sted b y h e r weight on o n e t o e , w h i l e s h e
' Idck' . t h u s su bstantially in creasing t h e l o a d required of
worked on the k i c k i n g a c t i o n w i t h the oth e r leg. e n s u ring
her
tru nk stabil izers. This series of exercises was fu n and it seemed like Sally would be
and ch allengi ng to d o
that s h e e m p haSized a relatively straight l eg a n d g l u teal fu nction i n p e rfo r m i n g t h i s acti o n .
Copyrighted Material
C LI N I CAL R EASON I N G I N AC TION : CASE S TU D I ES FROM EXPERT M A N U A L TH ERAPI S TS
continue to do her fa c i l itation exercises pri or to trai n i n g Sally ' s mother indicated that her coach was .
happy with this arran gement. I asked about attend ing a training session a n d ta lk in g to the coac h , but we quic kly real ised th a t t h is was not
a pra cti c a l option at
the time as trai ning was at 5 a . m .
• Treatm e n t 6 The next v isit took place 2 weeks later. S al l y a
little despond ent,
appeared
i n d ic a tin g that imp rovement
seemed to have pl a te a ued, with some return of her shoulder pai n d uri n g swimm i n g . She had i n creased the distance travel led du ring each session and her swi m tr a in i n g to 5 d ays a w e ek . Sally certainly could see some i m prove ment i n her shou lder control and aware ness while swi mming, and her use of body rol l
a nd kick, but was disap pointed because of th e return Fig. 1 1 . 9
Sid e-ly i ng fac i litation of dynamic control of
of shoulder pain , Her quadrant position , whi c h had
scap u lar a n d glenoh u m e ral positions at the catch phase of
been p a infu l e a rly on, was certain ly more p a i n fu l
the swi m stroke. Sally is using the therapis t's body to
than the last time it was assessed , w ith a slightly
si mul ate the water in the catch position , while th e
spongy end-fee l . There also a ppeared to be some sub
therapist applies tacti le stimulation to encourage, fir st, scapular setting in a n eutral position and then, rotato r cuff relocation prior to Sa l ly p u l l ing the ar m down through the downsweep action of th e swim stro ke; this is similar to h e r warm-up pool-s i d e exerc i s e .
tle swelli ng in the su bacromial/su perior capsular region of her should er. Isometric resisted rotati ons in 90 deg rees of nexion n ow reprod u ced the same pai n as provoked with the qu a dr a n t posi tion . Clearly the additional swimming was aggravating
enthusiastic t o contin ue t h e m a t home. This she was to
the shoulder problem and Sally's rotator cuff and
do in addition to the twisties exercises an d the ro tat or
scapu l ar control was n ot yet su rficient to cope wit h the
cu ff a nd scapul ar stabil izing work.
ex tra load , I pointed this out to her and asked how
In a d d i t i on, I spent some time worki n g with Sall y in
much o f a probl em it wou ld be to return to the regi
side lyin g usi ng tactile facilitati on and manual resist
men of 3 days swimming. She was rel uctan t to do this
ance to improve her rotator c u ff and scapular stabil
as winter pennant champi onships were on ly 3 weeks
izati on fur ther, i nitially at the catch phase (Fig. 1 1 . 9 )
away and she wa s keen to compete wel l in these. I indi
and later at t h e IInal stroke of the pull-through phase
cated that I fe l t that this wou ld slow do wn her progress
,
of her freestyle stroke . This manoeuvre w a s si milar to
and that, i f the champi onsh i ps were important. sh e
the pretrainin g facilitation exercise b u t was enhanced
would have to accept the slower rate of progress and
by the manua l contact. D u r i n g these exercises she was
do more to red uce i n flammation in her shou ld ers fol
encouraged to maintai n the TA c ontraction.
lowing each sw i m session . I suggested gen t l e th rou gh
I asked Sally and her mother whether they were
range m ovement with rotator c u ff con trol w h i le i n
hap py with the progress to date and whether they had
the warmth o f a shower immed iately after tr a i n in g fol
any particu lar questions; they seemed enth usiastic
lowed by ice massage to the sub-acromial space/rotator
,
ab out how thin gs were going. We discussed maintain
inter val area, with a fu r ther brief b u t deliberate rota
ing a reaJistic sched ule for Sally w i t h i n the con text of
tor cu ff facil itation session a fter the ice . I also su g
her sch oolwork and swimming req u irements . It was
gested that she increase her rotator cuff stabilizi n g
deci ded that SaJly should do one exercise session per
work d u r i n g her exercise sessions, aiming t o i n crease
day worki n g s peciftc a lly on the tasks set. In addition,
the rate of i mprovement in this fu ncti o n .
she wou ld work on
a repetition /awareness prog ramme
I n add ition , treatment t h a t day incl uded gentle
198 6 : Mai tland ,
d uring the d ay to facili tate cor rect motor programming
mobilization (Grad e rV---) (Magarey,
of scapu l ar and g l enohu m eral stabil izalion and would
1 9 9 1 ) of her glenohu meral j O i n t into the q uadra n l
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11 BI LAT E RA L S H O U L D E R PA I N I N A 1 6 -Y EA R - O L D LO N G - D I STA N C E SWI M M E R
posi tion . w ith G ra de IV-- s u ba crom ial di s lTacti o n
pe rfo rmed short of pai n . foU owed by Gra d e III-- m o b il ization in the same directi o n . Pain on tes ting of the
qu a dr a n t and on isometric rotator c u ff tes tin g was
red uced fo l l o w i ng the mobi l iz a ti o n and S a l l y was ab le to generate a dynamic rel o cati o n contraction more stron g l y in the 90 degree 11ex ion position . Mo re side
lyin g facilitation work on rotator cuff and sca p u l ar stab i l izing was then added . as at the l a st tre a tment . Sally ' s mother phone d a week later to say that the s hou lder pain during swimm ing w a s less and that the pain she did have was reduced co n siderably fo l l owin g the post-training regimen. S a l ly fel t
m o re
co n l'ide n t that
she would be ab le to co ntrol the pain better and. there fore. the c o ncern ex pres sed at the last visi t was al lev i ated somewhat. I s u ggested to Sal ly ' s mother that they continue to work on the s ame re g imen . with appropri ate progressions until after the w inter pennant competi
F i g . 11.10
tion unless they had further clifl'iculties . I also sugges ted
weighted ball in a simulated catch position while balancing
that SaUy take her theratu bin g to the p oo l and do her ro tator
Mini- plyometric throwing exercise with a
on the Swiss ball.
c u ff/s c apul a r facilitation exercise immediately
prior to entering the water and again three times durin g
d i fferent from the res t of the sq u ad . However. she
the tr a ini ng session.
fo und that the regimen reduced the a m ou n t of pain
to try t o maintain the pre
activation throu g h o u t the training sess i o n .
during the session and also seemed to i mprove h er stroke an d so was h appy to c o n t inue with i t .
• Treat m e n t
Her quadra nt position was less pa i n ful . the s u b
7
acromial area less swo llen, and h e r rotator cuff a nd
Th ree weeks later fo l lowing the c h ampions hips, at
scapular stab i l izin g contractions
wh ic h Sal ly ' s limes were imp roved , both Sally a n d her
more than I might h ave anti c ipated based o n the ra te
had
im proved
mother seemed much more reassured and enthusias
of progress to da te . Tre a tment consisted of more r ota
tic about her progress . r p o inted o u t to them that S a Uy
tor cu rr and scapular sta b ilizin g work in d i fferent pos
was not ideally b u il t for the load she wa nted to put on
itions and showing S a lly how she c ould work on this
that she was likely to h ave to pu t up with
with some ' mi n i-plyo metric' drills to m ake her exercise
s o m e shou lder pa i n if she wanted to c o n ti nue to train
sessions more interestin g . Th i s was achieved by m a i n
hersel f
a nd
hard and aspire to great ach ievements in swimming.
taining the stabilizing c o ntra c t ions wh i le th ro win g a
However. s h e had shown herself that she could minim
ten n i s ball a shor t dista nce to a wa ll, ca tch in g it o n
ize thi s with app ropria te work o n gene r al s trengt h and
return and throwin g it again as qu ic kly as poss i b le.
technique a n d faci litation of her rotator c u ff/scapular
This was done with Sally 's arm in a p O Sit i on of approx i
stabil izers . A lso, when the p a i n was present she cou ld
mately 1 2 0 de g ree s of flexion in the p l a n e of the
reduce it with the pretrai n i n g and post-train ing regi
scapula . She was able to ach ieve this quite re ad i ly.
men we had i n s ti tuted . T h is empowerment and con
even as the speed of throw and catch was i ncreased .
trol over the pa i n seem ed to h ave made a profo u nd
I showed her how to prog ress this exercise
difference to Sal ly. who was much hap p ier and outgo
main tainin g the control. Later, S al l y pr o g res sed to use
wh i l e
s.till
ing at this visit than at any other time. She seemed no
of a small wei g h ted b a l l . either in the same way or in
l on ger scared of her shoulder pain a n d n o l o n ger saw
c o njuncti o n with trunk stab i l iza tion o n the S wiss ball
(Fig. 1 1 . 1 0 ) . S he also be g a n some plyom etr ic wa l l
it as the end of her swimming career.
When I asked
what
effect intermitten t exer c ising
p u s h -ups with her arms in different posi tions of Hex
thro ug h the training session had had on her pain both
i o n , maintaining rotator c u ff control while wo rking
d u ring an d a fter t ra i n i n g , Sal ly ind icated that she had
th e sca p ular muscles (Kib ler, 1 9 9 8 ; Wilk and Arri go , 1 9 9 3 ; Wilk e t a l . . 1 9 9 3 : WW< and Vo i g ht. 1 9 9 4 ) .
initia l l y been reluctant to do it as i t wo uld make her
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C LI N I C A L REASO N I N G I N ACT I O N : C A S E STU D I ES F RO M E X P E RT M A N UAL T H ERAPI STS
REAS O N I N G D I S C U S S I O N A N D C L I N I CA L R EASO N I N G C O M M E N TA RY C o u l d yo u c o m m e n t on th e ro l e of p a l l i ative
of the pain and s trategies that can be employed , both by
treatm ent, s u c h as the m o b i l i zati o n s yo u a d d e d ,
the therapist and the athlete, to reduce or elimin ate the
i n t h e bro a d e r m a nage m e n t of a pre d o m i n a n tly
pain. The therapist should also point out that hi gh
muscle c o n tro l p ro b l e m ?
performance ath letic endeavo ur often places forces o n struclures that are beyond our ability t o control com pletely. This is particul arly the case if the athlete's bio
• C l i n i cian's answe r
mec hanical mal<e-up is not ideal for the particular
I n i t i a l ly, Sally ' s prese n tation i n d i c a ted very l i ttle p a i n w i t h a ny active or passive m ovemen t , but a n excessive r a n ge of movement a n d poor m uscle contro l . At t h a t t i m e , e m p h a s i s o n a d d ressing t h i s c o n t r i b u ti n g fa ctor was c l early th e highest pri ori ty. My hypothesis at the time was t h a t there was l i ttle i n tri nsic tissue d a mage and wh a t was present re l a ted more to conti n u a l irri tation than true pathol ogy. However. a t the poi n t w h e r e pall iative m o b i l i z a t i o n was added t o t h e treat men t, there was ev idence o f more obviou s provo c a tion of symptoms and some physic a l c h a n ges a round t h e s h o u ld er. Con tinued work w i t h the muscle con trol approach and a reduction in s w i m m i n g wou ld h ave a l l owed this aggravation
s w i m m i n g a nd not red uce the i n tensity of her train i n g . S h ort-term bene fi t could be gained fro m pallia tive tre a tme n t a im e d at red u c i n g the i nfl a mmation i n subacrom ial/superior
muscle performance and control arou n d her shoulders shou ld reduce her pain and , therefore. i mprove her swimmi ng, it was important that she understood that the repetitive load with swimmi n g might have been more tha n her biomechanical mal<e-up could cope with i n the long term. The muscles si mply may not h ave been able to work sufficien tly to stabi lize her shoulders fully. Providing her with immediate palliative strategies to reduce symptoms that were provoked gave her more confidence to work with some d iscomfort. rather than to let the discomior t overpower her.
to settle i n time .
However, it was i mportant to S a l ly at t h a t time to keep
her
sport. as was the case w i th Sa lly with her hypermobile shoulders. While a programme designed to improve
capsu l ar
area ,
thereby
reducing her p a i n , so that s h e could continue swim mi n g . While this tre a t m e n t was recognized as h av i n g n o l o n g-term e ffect o n h e r problem , i t did provide t h e necessary immedia te p a i n relief a n d al so al lowed
What was yo u r c l i n i cal a n d p hYS i o l ogical rati o n a l e fo r i n co rporati ng p lyometric exerci ses i nto h e r p rogra m m e when swi m m i ng does not req u i re the q u i c k ecce n t r i c-con centric change over that occurs with th rowi ng?
• C l i n i c i an 's answer There is a small plyometric compon e n t to swimming
S a lly to see that she s h o u l d b e able to control her p a i n
that is bei n g i ncreasi n gly recogn ized by swimming
herself with s i milar measures if she fo und t h a t t h e
coaches and rel ated health practitioners . Immediately fol l o w i n g hand entry, the arm reac h es as far forwa rd
lon g tra i n i n g aggrava ted h e r symptoms. This episode also gave me the opportunity to provide
as possible, p lacing a stretch o n the oblique abdom
S ally with further i nsight into the requirements of elite
inals, the scap u l ar retractors and glenohu meral medial
sports performance. If swimming continued to cause
rotator s . This stretch provides some stori ng of elastic
pain in her shoulders, she would be able to understand
energy i n the series elastic components of the rele
why and be able to come to terms with it and not neces
vant muscles (Wilk a n d A r rigo, 1 9 9 3 : Wilk et ai. ,
sarily ass ume t h a t the therapy provided was of no value.
1 9 9 3 ; W i lk a n d Vo ight, 1 9 9 4 ) . thereby e n h a n c i ng
A common feature of high-level athletic per formance is
the concentric contraction requ ired at catch. Recent
that athletes live and perform with some level of pain .
adva nces in tec h n iq ue emphasize i n i t i a t i n g the catch
To an athlete, the value of the athletic performance
from the pelvis, similar to the i ni t i a t i o n of the fo rward
is greater than the pain and the potential damage
movement of a throw, to generate more power through
inllicted . When a yo u n g athlete attends for treatmen t of
the powerfu l tru n k rotators rather than relying o n ly
a painfu l problem for the fIrst time, i t is the therapist's
on the smaller, less-efficient shoulder girdle a nd gleno
responsibility to expl ain the mechanisms for production
h umeral muscles. The side-lying PNF procedu res
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11 B I LAT E R A L S H O U L D E R PA I N I N A 1 6- Y E A R - O L D L O N G - D I STA N C E SWI M M E R
described above p l a ced S a l ly ' s trunk a n d shoulder g i r d le in a s i m i l a r posi tion to that at the c atch point i n the swim cycle. the r eby attempting t o repl i cate the muscle load . enh ance t h e co n tr ol req u i r ed in t his position a n d create a small stretch-shorten i n g com ponent. However. man u a l handl i n g and d ry land exercise cannot fu l ly repl icate the muscle r equire m e n ts i n the water. and tra i n i ng of the musc les in a stre tch - sho r te n i n g cycle in p os i t ions similar to those requ ired in the catch phase w as i nc l u d e d t o repl i ca te ( as closely as was p ossi b le on dry la n d) t h e ac t i o n t ha t was requi red of these muscles at catch . Use of a throw catch rou t i n e also e ncouraged a q u icker changeover from eccentric to conce n tric contraction t h a n is n o r m al ly p ossibl e i n the water. Phy s i ologic a l evide nce (Kom i . 1 9 8 6 ) also indi ca tes that eccentric m u s c le work is more energy efficient than concentric. so that g reater force can be created for the same amount of work. Therefore. if a patient has poor endurance. wo rk i ng eccen t rically should allow tolerance of longer workouts w i th the p o ten t ial for faster improvement (Bennett a n d Marcus. 1 9 9 4 ) . I n additio n . gai ns from eccentric s tr ength tra i n i n g a r e g reater than those from e q u iva l e n t concentric training. with re d u c t io n of oxyge n c o n sum p ti on d ur i ng eccentric a c t i v i ty indicating imp r oved n e u r a l coordination ( P r i d e n e t a I . . 1 9 8 3 ) . Therefore. the inclusion of eccentric wo rk i n Sally ' s programme was j us t i fi e d .
D
G iven Sal ly's ove ra l l pres e n tati o n , i n c l u d i ng h e r u n i q u e ' pai n experience' a n d res p o n s e t o yo u r m a n age m e n t th us far, what we re yo u r tho ughts rega rd i n g prog n o s i s . In answe r i n g this cou l d yo u h i gh l ight those featu res of h e r p res entati o n that you fe l t s u p ported a positive p rogn o s i s a n d t h o s e s u p porting a n egative p rognos i s ?
• C l i n i c i an 's an swe r My t ho u ghts reg a rdi ng prognosis at this point were very posi tive in the short term-more so than r had exp e c te d when we star ted out. Sa lly had been very compliant with her progra mme: her understanding o f the problem and the requirements to address it were sou nd . S he had de m o n s trat e d herse lf to be far more assertive and enthusiastic about her swimming than first appeared , and the response to the manage m ent programme had been very good so far. Sally appeared to h ave little i ntrinsic pa t hology in her
shoulders: her basic s w imm i ng tech n i que was sou n d . as evidenced b y h e r success prior t o t h e development of the shoulder proble m . and her motivation to s u c ceed was very hig h. She also had a very suppor tive a nd stable family and all the p ri v i leges that go w i t h a n a ffl ue n t lifestyle: opportu n ities t o t ra i n a n d compete a t w ha t ever level he r ta len t took her t o . the safety and security o f good frie n ds . and the l i fe ex pe r i e n c es pro vided by an e x cl u s i ve private schoo l . The questions raised earlier a b o u t a ' p u shy ' mother were not sup p or t e d d u ring the m a nagement pe r io d : her mother was shown to be compassionate and concerned but n o t overbear i n g . Her domination of the e a r ly sessi o n s was more re lated to S a lly ' s teenage s hyness a n d . there fore. u n w i l l i n gness to speak for herself than a ny th i n g else. A s S a l ly b ecame more confident w i t h me a n d happy w i t h t h e progress. h e r o w n pe r so n a l i ty c a m e to the fo re and her mother's d o m i n a n c e reced ed . There had been n o s u p p o r t for the hy potheses related to pos sible central mechan isms considered i n i t ia lly a n d little t o suppo rt t h e a ffective obstacles identifi ed a s p oss i ble . However. there were some features t h a t did n o t s u ppor t such a positive prog nosis. par t icu l a r ly i f a long-term view was take n . The m a i n one was S ally 's intrinsic hyper m obi l i ty. Such hype r mob il i ty meant that he r shoulders would a l ways be d is a dva n t a g e d when she swam comp a re d w i t h a s w i mm e r of simi l ar ability with less-mobile shoulders. She was u n l i k ely to be able to generate the same levels o f power thro u g h her shoulders as the less-mobile swimmer. thus redu cing her c h ance of achiev i n g the fa s t times necessary to co mpete a t the top level. If S ally wa n ted to achieve c lose to those times she wo u ld be required to contin u e w i t h a maintenance programme of scapu la r a nd g l e n o h u m e r a l s t abil izi ng tra i ni ng thr o u ghout her swi m m i n g career. Even w i th the d i scipl i n e req u ired to maintain the tra in i n g necessary to compete at elite level. co n tinue d comp l i a nce wi t h t he stabilizi n g pro gra mme may n ot be as good. with the pote n tial for exacerbati o n of her symp t oms . There is a high incidence of shou l der pro b l ems i n eli t e swimmers res u l t i n g from the highly repetitive n a ture of the sport a n d the long d i s ta n ces s w u m in trai n i n g by these athletes. Hypermobile shoulders. s ubjected to a h i ghly repetitive l o a d . a re l ikely to d eveLo p i ntrinsic wear and tear p athology over ti me. even i f their muscle con trol is maintained a t an opti m a l leve l . Superior labral damage. fro m the repet i t i ve shearing at the catch phase. a n d a nterior l ab r a l
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C L I N I C A L REAS O N I N G I N ACT I O N : C A S E S TU D I E S F R O M EX P E RT MAN UAL T H E R A P I STS
damage . rrom compress ion duri n g the pull th r ough ph a se or the stroke, are l ike ly to be coupled with ge n e r a l capsular irritation. The muscle co ntrol requ i red i n a hypermobi l e shou lder is greater t h a n t ha t in a
s hould er with less mob ility.
Aga i n , over ti me this may .
lead to we ar and tea r pa thology withi n the rotator cu rr.
with
associated
de ge n erative cha nges .
T he
anatomica l pla cemen t of t h e se m u scles a l s o mak e s them v u lnerable to ou ts i de i n fluences in the presence or poor control. With fa ti g ue of the rota tor culT a nd hypermobility or the s houlder the likelihood of develo p ,
ing subacromial or su bcoracoid i mpingement is h i g h a s a resu lt o f l oss of centr i n g o r t he humeral h e a d . w ith rotator cuff teari n g
associated with fr i c ti o n
traum a from the impin gement. T hererore, the long ter m prog nos is for S a l ly. if s h e c o n t i n ues to swim , is not as po s itive as the s hor t er term -
prognosis.
evidence beh i nd each p a i n mec h a n ism . s o u r c e a n d contri b u t i n g fac t or co n si dcred )
ciated
is s ues
contex t u a J
and
beliefs/ex pectat ions, perso n a l go a l s . co m mo n for
some
is
status, I t is
etc. ) .
Ill a n u a l t h era pists to t a ke
ei ther/or appro a c h . appro a c h
t he asso
( psyc hosoci a l
recog nized can
impo r t a n t .
as
no
m ovem e n t treatment is
Passive mobi l ization
an
whereby once a dy namic passive
l o n ger e v e n considered .
b e a n effec tive a d j u n c t to
tre at p a i n a n d also c a n improve mu scle fu n c t i o n /
m o t o r con t rol
through
the
relier of
the i n h i b i tory
effect or pain on muscle fu n c t i o n . In this case. wh i le recognizing t h at passive trea t m e n t
woul d
not have a lon g-term effect on S a l ly' s problem. the cl i n ic i an j udiciously used passive mobilization
means to identi fy
as a
provide immed i a te pain rel ief a n d to
m e a s ur e s
t he patient could
u se
hersel f
in
h e r own fu t u re self- m a n a geme n t. The
• C l i n ical
cl
i n i ci a n s '
progn ostic
reasoning
is bot h
broad and rea l istic in its consideratio n s . The
reaso n i n g c o m m e ntary
c is e of
exer
identifying posit ive a nd negat ive prognostic
be very u sefu l to (�lc i l i t a t e therapis t s ' rel1ection s . The pat ient 's im med iate pa i n
The c l i nician's a n s wer on the role of pallia tive
i ndicators ca n
treatment i n m a n a gement h i g h l i g h ts a d i ffic u l t d ec i si on ma n u a l th era p i sts r e g u l a rly face. t h a t is. should treat ment be d ir e cted at a hypothesized source or the symptoms or at a poten tial con
critical
tions are not rea l ised . a ret rospec tive cri tique of
and fu nctional status a n d t h e broader contex1 u a l fa c tors must all be taken into accou n t . When pred ic
as
tribu t i n g factor. Even when i t i s clear that both an:.
what was j u dged positive and negat ive.
necessa ry.
as
other prev iously less -considered factors. can assist
to t reat
to rol low. I n
a decision is sti ll re qu i r e d first. There is no simple rule
to
whidi
t herapists
to
re c ogn i z e where they
wel l
may
as
have
u nderemphasized or perh aps CO I11-
t h e end. as evidenced b y the clinici a n ' s reason i n g
overemphasized.
here, t h e decision m u s t b e based on t h e wei ghti n g
pletely d ism issed as not relev a nt d ifferent aspec ts of
or
the
patient's c linical
presentation
( s trength or
Outcome
the patient's presentat ion and pain ex perience .
reduced quicldy
if
she did not do the s pecific exercises
a imed at its f a cilitation She wa s h appy to c ontinue with .
Sally continued with t h is programme for sever al weeks,
this regimen for an extended perio d with the arrange
and she now u nd e rs tood how to progress it appropri
ment that she would phone for a further appoi n tmen t if
.
ately. She continued to get some shou lder pain with
she wanted some more ideas for exercise progression . ir
swimm i ng. par t ic u larly when she increased distance or
she felt she needed manu al racili tation to improve her
nu mber of sessions, but over the remainder of the \vll
s houl d er function,
ter she found an opti m al training regimen ( i ncludin g
sized that I co n sidered she would need to con tinue spe
sessions of
specific
exercises) that allowed her swim
ming to continue to improve without si g nifican t exacer bation of the
s houl d er
pain. She cer tain ly fouod that
or if she had
cifiC facili ta tion activities
as
any question s I empha .
long as she con tinued
swimmin g, and the commi tment to these would need to be propor tio nal to the amount of swim lTaining. as s he
she needed to keep up the exercise sessions and the facU
had already shown that the improvements ga ined were
itation exercises during training or she quickly devel
not
oped pain again . Sally also found that her awareness of
her to continue with the tr unk stabiliza tion and to work
pre activation and h er functional rotator cuff strength
hard on kicking s trengt h and technique with her coach
-
main tained withou t continued work. I e ncour age d
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1 1 B I LAT E RA L S H O U L D E R PA I N IN A 1 6 - Y EA R - O L D L O N G - D I STA N C E SWI M M E R
from some s h ou lder p a i n with her swimming. but she
t o lighten the load through her shou l ders a s much as was
had fo u n d ways in whic h s he could c o n trol that p a i n
possi ble.
S a l ly was ty pical o f m a ny you ng ath l e tes needi n g
a nd s he w a s able to understand t h e mech anics of its
to come to the rea l i s a t i o n t h a t top-level com petition
prod uction and perpetuation . Consequen tly. she was
tends to come w i t h a price: the pain assoc i a ted wi th
ab le to cope with her problem and contin u e to train
tra i n i n g a n d competition . She conti nued to su ffer
and compete at the top level.
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(J. R . A ndrews <lnd IC E. W i l le eds. ) pp. 5 4 3-5 6 6 . New York: C h u rc h i l l Livingstone. Wilk. K.E . . Vo i g h t .
M.L.. Keirns. M . A . .
[ n ter n a tio n a l J o u r n a l of Sports
m a n ageme nt of a l tered m o tor control
M e d i c i ne. 4. 1 7 7-1 8 3 .
arou nd the sho u l d er comp l ex . M a n u al
C ambetta . V. A n d rews . J. R . a n d
Therapy. i n press.
Dil l man . C.l. ( 1 9 9 3 ) . Stretch-sh orten i n g
Jensen .
C . M . . Gwyer. J . Hack. L . M . a n d .
S bepard . IC E ( 1 9 9 9 ) . Expertise in
Magarey. M.E. and J ones. M.A ( 2 00 3 b ) .
.
dri l ls for t h e u pper extremi ties : theory
Physical Therapy Practice. Oxford :
Spec i fic eva l u ation of t h e fu nction o f
a nd practical a p plic<ltio n . Tou r n a i of
B u tterworth-Heinemann.
force couples releva n t for stabilisation
Orthoped ic and Sports P hys i c a l
of glenohu meral j o i nt. Manual
Therapy.
Jones. M. a n d M a garey. M. ( 2 00 l ) . C li n i c a l rea s o n ln g i n the use o r m a n u a l
th erapy tec h n iques for t h e s h o u l der
Thera py. i n press. Magl ischo. E . W. ( 1 9 9 3 ) . S w i mm i n g Even
girdle. In Eva l u ation a nd Rehabilita t i o n
Fas ter. Mou n tain View. CA : Mayfteld
of the S h oulder: A n Impairmen t Based
Publishing.
Copyrighted Material
1 7 . 2 2 5-2 3 9 .
C H A PT E R
M e d i al c o l l ate ral l i gam e n t
12
re pai r i n a p rofessi o n al i c e h o c key p l aye r David M agee
� Tom i s
S U BJ E C T I V E E XA M I N AT I O N
a
professional hockey player who was inj ur ed
during the first
period of a game. At the time , he was
body checked by
an
opposin g player and at the same
swelling and to give the inj ury a chance to ' settle down ' . A prinlary concern a t this time was the i nsta b ili ty of the knee, as well as the possibility
that the inj ury mi ght
moment his foot caught in a rut in the ice while he was
be season ending . During the surgeon's assessmen t ,
weight bearing on the limb. With the bo d y check, a val
both t h e team trainer and team physical therapist were
gus stress was applied to the leg and the atWete fell to the ice. During the contact, Tom experienced
pain and
present and the fm dings s tated were
based on the
examin ation of the surgeon . It was felt that fo r the team
when he got up and tried to skate he noted that the lmee
trainer or physical therapist to repeat the tests wo uld be
did not feel right, and so he skated off the ice, The trainer
cou nterprod uc tive because of Tom ' s apprehensio n , the
questioned Tom on the bench and then took him to the
starting presence of muscle spasm, which may have
dressing room where the team doctor,
orthopaedic
affected the acc uracy o f some tes ts, and the desire to
surgeon, saw him, This game was the fo ur th game of
ensure the vascu lar clotting mechanism wou l d be
an
this seaso n , Tom had missed a l l of the pre-season
interfered with mini mally. Because the mechanism of
training camp and the beginning of the season because
inj ury was seen by the medica l personnel at the time of inj ury and because the inj ury was repl ayed several
of prol onged contract negotiations, So, in addition to the mechanism of inj ury, conditioning and timing may
times on video playback, it was fel t there was no need to
have been factors that contributed to the injury.
clear other j o ints or to do neurological testing. It was
On in itial assessment,
d etermine d
the orthopaedic surgeon
t h a t there was a va lgus laxity in the knee,
a
consensus opinion that the MCL had su ffered a third degree sprain and the ACL h a d p r o b a bly s uffered
a
first
one would normally
degree sprain. As muscle spasm had begun to set in a
expect to find with an intact liga ment. There appeared
defmi tive diagnosis was impossible and so trea tment to
to be some positive anterior drawer motion ind icating
minimize swelling and pain was immedi ately insti tuted .
withou t the ' abrupt stop' end-feel
inj u ry to both the medial coU ateral ligament (MCL) and the a nterior cruci ate ligament ( ACL) .
All
At the time of the i ncident, Tom was very appre
other tests
hensive about the extent of the inj ury and what e ffect
were nega tive, al though muscle spasm was be g inning
it would have in t he short term, in addition to his l o n g
to manifest itself. with the range of motion being
term prospects as a hockey playe r. A l th o u g h he had
limited . S trength was slig h tly less on the inj ured side as
an
a result of re!1ex inhibition ca used by pain. Tom
a t being i nj u red so soon after returning to the team to
u n d ersta n
d ing o f the i n j u ry, he was a lso a g i tated
was immedia te ly given anti-in tlamma tory medication
p l ay. He partly fe lt he was ' l etti ng the tea m down ' .
( d iclofenac: Voltarin Rapide) and s tarted o n a pro
I t also b othered h i m t h a t he should be i n j ured when
gramme of ice, compress ion , and elevation to prevent
he was i n ' the best s hape h e had ever bee n ' after
1 80
Copyrighted Material
1 2 MEDIAL C O L LATERAL LI GAMENT REPA I R I N A PRO F ES S I O NAL I C E H O C KEY P LAY E R
mm) a n d a g r ad e I me d ial opening
s pend ing a great d e a l o f time working o n his fi tness
translation o f 1 0-1 6
o ve r the sum mer. Because of the apprehension on
(a valgus gappin g on the medial side of 5 mm on testing
Tom 's part. the medical tea m decided t h at treatment
in exte n sion ) ( K e nne d y. 1 9 7 9 ; Muller. 1 9 8 3 ) . He also
wo u ld be very conservative.
h ad a lmee that hy p er ex t en de d As Tom d id not com .
A fter the a p plic a ti o n o f ice. co mpress ion and e l eva tion. To m was p l a ce d in an immobilization brace with
crutches to protect the knee and wa s given an a lges ic s for pain c o n t r o l
fn this case. the knee immobilizer
.
p lain of any p r ob le m s. no special programme for
knee was instituted in the intervening ye ar s
the
.
At s urgery. t he p a te ll ofem or al artic u l ation was fou n d to be normal and the medial and l a teral femoral
brace consisted of an open foa m sleeve. which was
gutters were devoid of loose bodies. The s upra p ate lla r
clo sed with six velcro straps ( th ree above knee. th ree
pouch was normal and only mi l d l y hy pe r a e mic The
below knee) and medial and l a tera l articulated bar su p p o rts . The b race was removed fo r re h ab i l i ta tio n . The next day Tom was seen by the athletic tra iner.
were normal. as were the medial fe m o r a l c o n d y le and med ial
who conti nued the ice. compression and eleva tion treat
looked normal throughout its l e ngth ; a lth o u gh i t
ment. and in add i t i o n . insti tuted qu adriceps setting
appeared fIrmly attached arou nd the periphery. there was a small amount of fray in g at its posterior attach
( i s o m e t r i c q ua dr ice ps in extension) a n d co-contraction
.
l a teral femoral condyle and l a te r a l t ib i a l c on dy l e
tib ial con dy l e . On first v i e w i n g the medial menisc u s .
o f qu a dri ce p s and hamstring exerc ises to main tain
men t . T here was no teari ng wi thin the intersubs tance
musc l e activity. Tom was able to do the exercises
of the medial meniscus . but there was some disr u pt i on
with no ap pa re n t d i flku lty. This same treatment was
of the m e nisc o tib ia l fIbres in its u ndersurface, giving
continued for
2 d ay s . Two d ay s after Tom was inj ur e d
.
a small
am o u nt
of increased mo bility to the meniscus
he u nderwent a magnetic resonance imaging scan.
when probed . The surgeon d e c i de d that this small loose
which ind icated that th e ACL was intact and that th e
part of the meniscus could be c augh t or an ch ore d in
MCL h a d suffered a third d e g re e strai n or rupture . thus
the su t ur e used to repa ir the MCL. The in t e rcondy l ar
'
'
con rlr mi ng the clinical diagnos i s . Over the n ext two
notch showed a cruciate l ig a m e n t with all fib r e s intact,
d ay s u n t i l su r ger y Tom received ice. compression . ele
but the fibres themselves demonstrated a s m all amount
vation . and range o f motion exercises to the knee to
of looseness when probed , as if t her e had been a preVi
.
control the swelling and to kee p the pain at a mini
ous se co n d d eg ree tear of the i n tersubstance tissue.
mu m . T h e knee was taken out of the brace while the
There was a small amount of fresh bleeding ar ound
athlete performed the exerc ises. C r u t ches with partial
the femora l attachmen t of t h e fIbres o f the ACL . Th e
we ig h t be a r ing were s t il l u sed by To m
-
surgeon fel t that the new inj ury to t he ACL was prob
.
ably i n s i g nift c a n t and i t was deemed un necessary to tig h te n the structure. Having i ns p e c te d the knee
Su rge ry
j oi n t , the s ur g e o n r e m o ve d t h e ar th r os c o p e and made
Five days after the injury occur red. Tom undenvent
a small me d i a l i n cision . On v ie w i n g the MCL , the s u r
arthroscopic s urge ry to the right knee to repair the MCL
geon noted a complete tear, which was t he n r epa ir e d
and to re a tt ac h the m en i s c o tibi a l fibres. The prev ious
t hro u g h the sa me incis i o n . Final ly, the incis ion was
history indicated that Tom had inj ured the sam e knee
s u tur ed a n d
while pl ayin g in col lege. ft was recorded in his preseason
geon ' s postopera tive plan was for a very con tro l led
team 6 years ear
r e h a b i l it a ti on pro g ra mme avoid i n g valgus s tress to
assessment by the pro fe ss io n al h ockey
lier th at he had a gr a d e II Lachman's test ( an an te r i or
the kn e e
a
pressure d r e ss i n g app l i ed . The sur
.
R E ASO N I N G D I S C U S S I O N A N D C L I N I C A L REASO N I N G C O M M E N TA RY What was your i n te rpretation of the fi n dings at su rgery an d the subsequent surgical repai r
Based on clinical fIn d i n g s . the m ag n e ti c re son an c e
with respect to you r plans fo r manage m e n t, precautions req uired and the patien t's prognosis for recovery!
• Cl i n ic i an 's an swe r a n d su r gica l fI n d i ngs a decision was made to begin .
s tre ng t h e n i n g and range of motion exercises using
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C L I N I C AL R EA S O N I N G I N ACTI O N : C A S E STU D I ES F R O M E X P E RT M A N UA L T H E RA P I STS
pain as a guideline as soon as the athlete wa s able.
The surgeo n ' s p h i l o so phy was that there was no need to restrict exercises to certain ranges of motion as l o n g as the exercises were done care ful l y and with
control
.
a l th o ugh no attem p t was made to i ni ti ate
a ny v a l g u s stress motion at this stage. The su rge o n s '
th i n k i n g was tha t. i t" he had done a p ro p er repair. con trolled ran ge of mo tion exercises within the p a i n - free ra n ge would not h ave an adverse effect on the re pa ir
.
In addition . cryo th era py was and pa i n . The prognosis for
used to control swel l i n g recovery was exce l l e n t
b e c a u s e the su rgery was successful a n d t here were no com p l i catio n s . the p a t i en t was very fit and moti vated . a nd the rehab i l i tation program me was i n iti ated belore s u rgery and conti n ued w i th o n ly on e d ay off for su rge ry.
• Cli n i cal
reaso n i n g commentary
The clinician's reference to the surgeon's ph ilosophy and th ink i n g
rega rdin g
postoperative managemen t.
h i ghlig ht s the col laborative decision making essen tial
approach. Although n ot such . prognoses. like diagnoses. represen t clinical pat terns. Qms ide ra t io n of pro gn o sis . along with positive and negative features of the in
a
multidiscipl i n ary team
always thought of
as
presentation that may influence the prognosis ( relat
ing to both the perso n and t he problem ) will assist cli to i mprove their prognostic decision ma king import a ntly. when a progn ostic hypothesis does nOI eve ntuate. the clin ician should then take time to renect on why, includ ing considerat ion of aspects of the patient's presenta t ion that perhaps were under or overweighted at the i n i tia l assessment. .
n ic i a ns
.
p ostsu r gica l assessme n t of the knee was requ ired . History i nd ica ted the knee was pain fu l fol l ow i n g the
• Stage
s urge ry Observation s h owed the knee to be held in .
1
approximate ly 1 5 degrees of l1exion. with a 1 5 cm wide
Because of the nature of the inj ury elld the antici p ated
e l astic/ace/tensor ba nd age appl ied. O n re mov i n g the
long re h abil i tat i o n programme . it was te a m practice
elastic band age. the wound area was clean and s h owed
t h a t the tea m physical ther ap ist become the dominan t
no ind ication of i nfec tion .
caregiver. providing regular reports (at least two or three
cool . a l though sl i g h tly warmer t h a n the u n i n j ured
trainer,
On
p al p atio n the knee was .
who is the coordin
kn ee , es p ec ia l l y a dj ace n t to the s urgic al scar. Active
ator of medical services. and t h e team p hysi c i an, an
moveme n t tes t i n g demonstrated th at the ra nge was
times
a
week) to the team
orthopaedic surgeon who performed the surgery.
restricted to 1 0-4 5 deg rees by pain an d a soft tissue
When Tom was seen by the s p or ts p hysic a l thera
c a ps ular end - fee l . with obvious musc le weakness.
pist fol l owi n g surge ry, a regime n o f ice. compression,
notably of the vastus medi al i s This was confirmed
elev a t i o n a n d quad riceps setti n g a nd co-con traction
resisted isometric tes ting . with a graded strength of 3 / 5
isometric exe rcises was i nstituted immediate ly. O n the
for the q u adrice p s in the range of motion available. The
.
.
00
second d ay, a range of motion exercises were added
h a mstr ings
w i t h i n the pain-free range to try to res tore range of
ran ge of motion available. Passive movement indicated
motion. A n a lg e sic medication was used as we l l to
a soft capsular end-reel in to both flexion and exte nsion .
demonstrated a stre ng th or 4 + /5 in the
h ad
his surgery t he
con trol pain . A l tho ug h this p a i n was real to Tom . it
As Tom
must be remem bered tha t his p a i n to lerance was
li gamen tous testing was perJormed. Sensory tes ting
j udged to be low. Depend i n g on the s t a t e of the knee,
was negative except for a 5
a n ti - i n t1ammatory medica tion s were used fro m time
surgica l scar. which was numb. Interstitial swe l ling in
to time by the s p orts p hy s i cal the ra p is t in cons u lta
the knee was evident , but swe l li ng i.n th e j oint was min
tion wi t h the or th op aed ic su rgeo n . If there was evi
imal. Mobility of the patella was lound to be s l ightly
j ust had
em
p revious day no .
area distal to the m e di al
dence of overuse in th e knee (swe l l i n g or pai n ) . the
restricted med i ally and la terally because of interstiti a l
a n t i -i n l1ammatory d r ugs were used to co ntrol symp
swelling bu t p ate ll ar tracki ng appeared norma l . .
toms and treatment was mod ified. When first see n by the sports physi c al thera p i s t
.
Tom presented with the knee held in sli g h t flexion
• Stage
2
i n a n 'off- the-shelf ' knee brace. A lth ou g h the thera
Early i n the tre a t ment programme. Tom showed
pist had been i nvolved i n the i n i tial assess me nt . a
that he was a nxious to
Copyrighted Material
i m p rove
a nd d emons trated
12 M E D I AL C O L LAT E RA L L I G A M E N T R E PA I R I N A P RO F ES S I O N A L I C E H O C K E Y PLAY E R
a certain a m o u n t o f fru s tration at t h e slow matio n , not the t h erapis t ' s ) rate
of
( i n h i s esti
improvement. The c on ti n
u a lly
in retur ni n g to the team because he was
c a u sed b y s a l ary
n ego ti a tion s with
a
'
h old o u t '
the tea m and had
had
n o t attended the tra in ing camp at a ll . In fact. he d id
to adv ise him that he was prog ressi n g a t a rate tha t
n o t retu r n to the tea m until wel l a fter the fi rst month
wo u ld be considered q u icker t h a n nor m a l . but th a t
o f league pl ay He fel t he was i n the bes t sh ap e
tissue recovery wou l d ta ke time progressing fr om t h e
ever been in prior to the start of the seaso n ; to h ave
i nfl amm atory p ha s e t o t h e fib ropl a s i a p h a s e , a n d
t h i s i nj u ry occ u r d uri n g o n ly his fo u r th game after
therapist treating Tom fo und th at h e
he h a d
.
fi n a l ly t o t h e maturation p h a s e . W h i l e Tom seemed to
retu r n i n g presen ted a q u i te sign ificant psychologica l
understand what t h e thera pi st was say i n g , it d id not
b lock for the pl ayer. The other fa ctor was Tom ' s rela
make i t a ny easier for him to accept that he had been
t i vely low pa i n tolera nce, which led h i m to bel ieve he
inj u red .
was
Part of th e
reason
for t h i s is t h a t he w a s l a te
n o t i mprov i n g q u i c k ly e n o u g h .
REAS O N I N G D I S C U S S I O N A N D C L I N I CA L R EASO N I N G C O M M E N TA RY
D
main th is wa s prob ab ly a way at his (in his v i ew ) s low
You have desc r i bed a psychological bloc k.
G iven the inj ury, Tom conti nued t o work o u t t o
H ow did this manifest? What were the key
ta i n h is gen eral l1tness Part of .
featu res that emerged in either the subjective
of c h a n nel l i ng his fr ustra tion
examination or in later di scussions through
progress, but this activity was to later lead to problems
the treatment that enabl ed you to recogn ize
of general fati gue and co nce r n about the effect of fa tigue on the heal ing process of his i nj u ry. Bec a u se he
th is pattern?
was one of the top athletes on t h e te am , his inability to
• Clinician 's an swe r
contribute to the team pro b a bly a l so led to fr ustra tion
The psychologica l block was indicated by Tom ' s a nxi ety at n o t getti n g better or not i mproving as fa st as he thou ght he shoul d . This frustration was conti n ually demo nstra ted by Tom in his qu estioning of his progress and his i nj u ry such as why he was not gettin g better .
fa ster and why the pain was not gO ing aw ay and the .
depressi on he demonstrated when things d id not go the way he wan ted. Tom wou ld demonstrate this depres sion by
his demeanour (slouching, swearing to h imself. grab b i n g a n d squeezing things) .
addi bec au s e he
and the feelin g he was letti ng the team dow n. In tio n , To m m ay have h ad
a
fee ling of guilt
was late j o ining t h e team as a res ul t of the con tract h o l d out. Tom' s low p ain tolerance was also a com plica t in g facto r. Thro ughou t the
tr eatme n t
.
To m was
conti n u a lly assured that he was progressing very we ll and that a ny se tbac k s h e experienced were part o f the healing process and . i n part. a res ul t of the agg ressive tre atment. The
clinicia n had to
m o n i tor p rogress very
care fu lly and watch that Tom was not being pus hed ' too h ard ' . Later i n the treatment programme (when h e bega n skatin g ) , Tom w a s g iven a n opportu n i ty to acco mpany the team o n one of t he road t r i ps w hi c h .
The indi cations of a psychological block
helped his psyche a great deal. The psychologica l over
we re identified at only 3 days after su rgery. At this stage, what were your thoughts on the significance of the psychological aspect of his presentation for yo ur man ageme nt?
l ay may also have affected h is pain to lerance. However, even before a n d s ince the injury. Tom showed simi l a r low pain tolera nce w i th other i n j uries. While o n e might
think i t wo u l d be wor t hw h ile t o sen d him fis h some s i mil a r relaxing activi ty, s u ch an action '
ing' or
• Clinician 's answer
wou ld be even h arder o n the ath lete because he wou ld
While i t is common for a n i nd ivid ual to be conce rned
feel he was not doing eve rythi ng he should to get
abo u t his/ her inj ury, To m spen t an inord i n a te a mount
bet ter. During the seaso n , these athletes o n ly get
d i sc us si ng his inj u ry. its progress and h is res ulting frustration at not being back with t he te a m .
abo u t 1 d ay per month in which they are not involved
of time
in hockey-rel ated activities .
Copyrighted Material
: .
C L I N I C A L REA S O N I N G I N ACTI O N : C ASE STU D I ES F RO M EXP E RT M A N UA L T H E RA PISTS
• C l i n ical
reaso n i ng c o m mentary
be at tended to. and even screened for. with the v iew of
The key issue here. as discussed i n Chapter 1 . is that
identifying where the patient's psychosocial status
patients ' psychological status . includ ing their u nder
may be interferin g with or cou nterprod uct ive to their
s ta n d in g of their proble m s and man a geme nt and
recovery. By givi ng this dimension of
how they a re coping with the effects their problems
entation the same consideration that is normally pa i d
are having on their lives. can have significant i n flu
to
ence
greater ski l l s in assess ing for and recognizing p attern s
on
their pain perceptio n . the responsibil ity they
physical
impa irment.
a
therapists
patien t's pres can
de velop
take in the ma n a gement process and ultimately their
of psychosoci al presen tations that
o u tcomes Like physical clinical syndromes patients '
sus counterprod uctive. As is the
psychosocia l status will present in patterns . However.
pa tient. management can t he n be varied accord i n gly
\-" ith patterns of physica l impa irement. care is
and prognosis viewed with appropriate consideration
.
as
.
needed not to ove rly ' box' a patient's psyc h ological
are
productive
case
ver
wi th this
to these is s u es .
status . Rather. cues of psych o so c i a l problems should
In a n attempt to a l leviate Tom ' s fru s tratio n . he was
wa l king outside while wearing the brace ( it was wi n ter
put on a fi tness progra mme for his u pper body and
in Can ad a ) . Whi le the in creased pain c a u sed Tom
u ninj u red leg 3 days after su rgery. This action was
some conce r n . the res u lti n g ir ritation settled dow n
taken to get Tom ' s mind off his inj ury and to m aintain
within 1 d ay and he was able to continue w i th his nor
h i s cardiovascu lar fitness. The fitn ess prog ramme was
mal tre atment a n d fitness regimen s. Ten days a fter the
d eve loped by the team fi tness consulta nt with i np ut
operation. the surgeo n removed the su tures . Tom still
from the team phys i ca l therapist. Seven d ays post
demonstrated a l ack of 10 de gree ex ten s i on be ca u se of
s urgery. Tom bega n to use the bi cyc le ergometer with
ca ps ul ar sti ffness. In the ea rly stages of trea tmen t it is
n o res i sta nce in an attempt to restore more of the flex
common practice with this med ica l team to work
ion range o f motion . I n i tia lly. Tom was given electrica l
within the ra nge available b ut n o t to p u s h th roug h
.
muscle stimu l a tion to the q u a dr i ceps because he was
p a i n i n to fu l l ex ten si on
having trou b le ' t u r n i n g on' the q u adriceps to extend
ava i l ab le n atura l ly Tom wou ld have been worked i n to
.
If fu ll extension had be e n
.
the knee. Once a good co n trac ti on of the qu adriceps
th at range.
was a c h i e ved (two treatments ) . the e l ectrica l s timul a
degrees. Qu a driceps s tren gth had i ncreased to 4 / 5
Flexion h a d i mp roved to about
1 20
tion was di scon ti nued An i nteres ti n g findi n g w i t h thi s
within the ex is ti n g ra nge whi le ha ms tri ng strength
patient w a s tha t he demonstrated only mi n ima l
wit h i n the availab le range was no rm a l . Passive move
.
.
swe l l i ng (swel ling only s lig htly evident with the swipe
ment testing at this stage i n dicated a capsu lar end - feel.
test) a fter the su rgery and th rou ghout the fu l l rehabil
However. because the ti ssue was in the early fi bro
i ta tion prog ramme. The main g u i d e u se d by t he phys
p l a si a phase of heal i n g . it was ['e lt that i n creases i n
ical therapis t in d etermi ning how far Tom could
ran ge of motion wo u l d be attempted pr i mari ly by
exercise was the pain level . Because To m ' s pain toler
ac tive range of motion exercise s . w i th some gent le
a nce was low. however he was en coura ged to d o con
passive ra nge of motion elastic stretch i n g to provi d e
trolled activ ities even if they were u ncomfor table.
o n ly a sma l l amou n t of h ea lin g stress to t h e ti ss u es .
.
P rovid ed
the
pain or d iscomfor t ended re latively
qu ickly a fter stopp i n g the activi ty. it was felt the inj u ry was n o t bei n g overstressed . Swe l l i n g pl ayed a very
• Stage
3
i n s i g n ificant role. a nd even when pushed, the restrict
In order to retra in the proprioceptive feed back system
ing factor was pai n not s we l l i n g D u r i n g this time and
affected by the s u rgery. propr ioce p tive and control
s u b s e q u e n t weeks. Tom wore a n off-the-shelf fi b re
exerc ises were begun. Exercises incl u d ed wei ght shil't
.
glass knee brace presc ri bed by the s u rgeon to protect
ing. bal ance exercises (one legged ) i n combin ation
his knee med i ally and latera l ly. while al l owi n g flexio n
with body bl ad e (Fig. 1 2 . 1 ) . ba la nce board exercises
and extension w i t h i n the ava i l able range of mo tio n
.
(Fig. 1 2 . 2 ) . use of a b a l a nce m a c h i n e . as well as more
Nine days a fter t he i n j u ry. Tom experienced a sud
vigorous cl osed k i n e tic c h a i n q u ad ri c eps a nd ham
d e n extension force on his knee when he slipped on ice
stri n g exercises ( F igs 1 2 . 3 a n d 1 2 . 4 ) . i ncluding si n g l e
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1 2 MED I A L C O L LATE RAL L I G AMENT REPA I R I N A P RO F ES S I O N A L I CE HOC KEY PLAYER
F i g. 1 2 . 3
Ath l ete on i n c l i n e p l a n e u s i ng body weight as
res i s ta n c e . N ote the u n sta b l e base.
Fig. 1 2 . 1
Exa m p l e of oscillating body blade used for
prop rioceptive tra i n i ng.
Fig. 1 2 . 4
Ath l ete d o i ng s i ngle l eg pres s . N ote knee
flex i o n d o e s not go past 90 degre e s .
correctly i n the available range were all owed . These exercises provided a s m all heal i n g stress to the i n j u red tissues. as we l l as range of motion and strengthen i n g effects. The progression of exercises was b a s e d o n t h e ability o f Tom t o con trol t h e exercise h e was asked t o do a n d on t h e pain response. Very speci fic instructions were given to Tom and i f h e devia ted he "vas stopped to prevent incorrect movement patterning from devel op ing. When Tom demonstrated an ability to do an activ ity the repeti t i o n . weight used or time were increased. .
A t the same time. Tom's work on the bicycle ergometer Fig. 1 2.2
Ath l ete on ' Profltter
>®
(dynamic balance apparatus,
re p rod uced w i th p e r m i s s i o n of Fitter I n te rnatio n a l I n c ) .
increased from 5 minutes with no resista n ce to 2 0 m i n u tes wit h resistance n o w being i m p leme nted . The seat height was modified as h e went through the exer
leg wa l l s l i d es and tu b ing i n to extension w h i l e weig h t
cise regimen. w i th the height lowered every 5 minu tes
bearing. W h e n d o i ng t h e exercises, t h e therapist
u ntil knee l1exion became uncomfo r table.
watched to ensure t h a t correct. controlled motion
One of the problems th at had to be dealt with e arly
occurred. Ofte n. beca u se of inj ury. proprioceptive feed
i n the reh abilitation process was the n o ticeable q uadri
back and the abi l i ty to c o n t� o l motion is lost to some degree. Consequen tly. on ly moti o n s t h a t Tom could do
ceps lag that developed before fu U exte n sion was achieved. Diligent work by Tom , however. led to full
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C LI N I CAL R EASON I N G IN AC TION : CAS E STUDI ES FROM E X P E RT MAN UAL T H E RA P I S TS
as well as ascending/descendin g stairs at speeds (slow) at which he felt comfortable and the therapist felt he cou ld control. In add i tion , on the balance m achine, target train ing was instituted with the targets designed to increase the valgus stTess to the MCL (Fig. 1 2 . 5 ) . By concentrating on keepi ng the ' dot' on target. Tom was working on main taining control whi le
streSSing
the
MCL an d facilitating the mechanoreceptors in the jOin t and muscles .
• Stage
4
Ab out 3 weeks followi ng the surgery, w a s i nstitu ted t o faci litate fu r ther t h e
ultraso und healing a n d
fibroplaSia phase of the tissue. It was felt by the physi c a l therapist that. given the normal continuu m of soft tissue healing (clotting phase, in flamma tory ph ase, fibropl asia phase and maturation phase ). Tom was now wel l into the fibroplasia phase of heali ng and at t h is stage ultrasound would be effective in he l ping stimulat ing co l lagen form a t ion . The end-feel a t
this
point was
still tissue stretch. bu t the pa in Tom was feel i n g on Fig. 1 2 . 5
Ath l ete on balance mac h i n e . Base may be
static or dynamic. Ath lete is concentrating on keep ing h i s cen tre of gravity by viewi ng the computer s c r e e n a n d either statica l l y or d y n a m i c a l l y main ta i n i ng the ' ba l l '
passive stretch was decreasing. It was als o found dur
ing application of t he ultrasound to the medial side o r the
knee,
which was the area o f origi n a l n u mbness.
that this are a had become extremely hypersensitive to
active ex tension wi thi n about 10 days of accomplish
to re p rather t han just a low pain tolerance. By con tinued use of the ultra
ing full passive extension range of motion . This lag was
sound over the area and by giving in structions to Tom
the movement of the sound head. This appeared
i mage cen tred .
resent a true decrease in pain threshold
of i n i tial concern because, as long
as it
was present, i t
indicated t h a t he did not have control i n part o f his
to rub the area gently w i th
a
skin cream to help to
desensitize the tissues, the hypersensitivi ty decreased
extension range. making him potentiaUy vu lnerable to
over a period of time although the numb area re maine d .
injury or re-inj ury. The exercises included quadriceps
Tom continued to work out to matnta i n h is physic a l fit
setting exercises. wall sl ides . 90 degree squats and
ness. In fact, it was fel t by the physical thera pist that he
spending
extension against tubing resi stance. With full exten
was working out too hard,
sion and the ability to do closed kinetic chain activities
working on his physical fi tness. Because he was becom ing exhausted from worki ng so hard to
and leg straightening exercises. Tom
began j ogging very sl owly forwards and backwards .
a
day
the other parts or his body main tain a nd improve his fitness level . it was
with no difficulty and no adverse effect. more vigorous open ki netic chain activities were insti tuted beyond the
quadriceps setting
6-8 hours
hypothesized that this may have been impeding the healing process.
REASO N I N G D I SC U S S I O N A N D C L I N I CAL REASON I N G C O M M E N TA RY
o
What is the pathophysiological basis for gen eral fatigue to interfere with the heal i n g p rocess !
• C l i n i c i an 's an swe r
.
Gene ral fati gue can be t he resu l t of severa l factors. Fatigue may be cen tral or periphera l . both of which
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1 2 M E D I A L C O L LAT E R A L L I G A M E N T R E PA I R I N A P RO F ESS I O NA L I C E H O C K E Y PLAY E R
may direc tly o r ind irectly a ffect t h e hea l ing process. Metabol i c fatigue is prima rily periphera l .
lea di ng
to reduced ATP. l o wer bl ood gl ucose leve l s . musc le glycogen depleti o n . de hydra t i o n . and loss o f elec tro lytes. Neu romu scular fa tigue. w h i c h may occur peri phera l ly or c e n tr a l ly. c a n resu l t i n substances competi n g for receptor s i tes . in creases a nd
with
cholin esterase
acety l c h o l i n e decreases
leading
• C l i n i cal
reaso n i ng co m m entary
The biomedical k n ow l edge evident in this a n swer. along wit h the c l i n ical i mplication n oted i n the cl i n ician 's last sta temen t, highlights the comb i n ation of
biomedical and c l i n ical kn o wl ed g e th at con tribu te to ex pe rt therapists ' orga n ization of professional
to
kn o w l edge The cl i n i c i a n ' s hypothesized i nvol ve
impai red neuro m u scu l a r tra nsmission a n d /or propa
ment of the en docri ne system il l u s tra tes a broad per
gation of a muscle action poten t i a l . a s well a s redu c e d
s pec tive beyond the obvious l oc a l
m o t o r un it recru i tm e n t and a p sychological ove r l ay.
repa i r and supports the value of i n c l u d i n g pathobi
.
tissue i nj ur y /
es pec i a l ly i f the fa tigue is c h ro n i c . Electrop hysiologi
ological hypotheses in one's clinical reason ing.
c a l fa tigue l e ads to decreased membrane po te n ti a ls .
Such considerations should encourage therapists to
A l l of the types of fa t i g ue a ffec t the fo rce-generating
be alert to the l i nks between the va ri o us i nput. pro
c a p a c i ty of t he muscle as we l l as affecting the ' b uild
cessing and output mechanisms that are known to
i n g blocks' of re pair through s tress o n the endocri ne
exist. For example. similar to
syste m . w h i c h wi l l . i n tu r n slow the reh abilitation
patien t's observed fru s tration may also have been
,
progress i o n .
t he
fatigue,
c o n t rib u t i n g to st r ess-re l ate d end ocrine effects such
as a l t e red sleepin g and compromised healing.
D
this
SkUled
c l in ica l reasoning requires a h jghly developed a n d Do y o u fe e l th i s pati e n t'S psyc h e , w h i c h y o u h ave
contextu al ly releva nt o rga n i z ati o n of knowled ge.
al ready h igh l ighted as a p ro b l e m , cou l d
Contemporary manual th erapy requires that th is
a l so be contri b u t i n g t o h i s fa tigue a n d hea l i ng
know l ed ge base includes u nderstanding of the inter
c a p a c i ty?
re l ati o n s h i ps between the different body systems ( e g psychological st atus, sensory-motor, endocri n e .
.
a n d immune system s ) .
• C l i n i c i a n 's answer
screening
questions
for
di fferent systems, management. i n cl u d i ng
symptoms of impairment i n the
Tom's psyche may h ave c o m p o u n ded the fatigue
and
and how best to modily
overtra i n ing p r o bl em s . O fte n , espec i a l ly in the e a rly
appropriate referral when i m pai rme n t i s suspected .
stages, To m r e p o r ted d i ffi c u l ty with sleep i n g and
While it is not poss ib le lor the manual th erapist al so
t ired ness, not bec a u se o [ t h e inj u ry. b u t bec a u se o f
to be a psychologist. endocrinologist a nd i mmunolo
having ' n o t h i n g to d o ' during t h e d ay a n d even i n g
.
a lt h o u g h he spen t an i no rdi n a te amount o f time
' working out' .
gist. we are o ften the firs t person w i th wh ich the
patient shares s uch symptoms. a n d as s uch it is criti cal that manual therapists at least have the knowl edge and awareness
• Stage
to seek further consultati o n .
To m ' s reaction to t h e new l o a d . Tom was c o n ti n u a lly
5
monitored during the exercise, with the therapist noting
By 3 weeks , Tom was d o i n g one- legged wal l sl ides as
any change in symptoms wh ile ridi n g the bil(e, after
wel l as balanC i n g exercises, l u nge exercises . a n d sev
treatment. and before beginning treatment the next day.
eral d i fferent quadriceps exercises. Ball b o u ncing exer
Tom was made to u nderstand the difference between
c i ses were instituted to im p rove fur t her l1ex ion ra n ge
stress pain , which djsappeared when a ctivity stop ped ,
of moti o n , pro prioception and b a l li s t i c a l ly con trolled
and pain that l in gered after the activity stopped , ind icat-·
much stress was applied to the knee. By 4 weeks,
mot i o n . A s we l l . resista nce was continu aUy added to
ing too
the bicycle ergometer exerc ise. The a m ou n t o f resist
Tom had progressed on the bicycle ergometer to approx
a n ce set o n the b i cycle ergometer was determined
imate ly 1 0 0 watts resistance and the seat had been low
by the desired stress to be pl aced on the knee, and not
ered close to
by
desired
card iovascul a r tra i n in g
normal funclional levels.
e ffec t . The
As wel l as doing exerc ises with the therapist o ffer
desired level o f stress was d e termi ned subjectively by
i n g resistance or u s i n g t u b i n g , the use o f exercise
a
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: :
C L I N I C A L REASO N I N G I N ACT I O N : C A S E STU D I ES F R O M E X P E RT M A N U A L T H E R A P I STS
mach ines was also instituted (leg press, h a mstrings
skating type motions. Resistance was i n i ti a l l y applied
m a c h ine, abductio n / adduction machine with resist
above the knee, but as the hea l i ng process progressed
a nce above knee) . Repe titions a nd weight were set
the resis tance was appl ied to the tibia to i ncrease the
d ependin g o n Tom's abi lity to do the req u ired repe
healing stress to the tissues that had been repa ired .
titions wi thout ad verse symptoms . Alternate days
With these functi o n a l activ ities , Tom's a b i l i ty to con trol
were used for stre ngth ( h i g h load . low repetitions) and
th e m ovemen t was the decid i n g factor concerning
e ndura nce
repetitions and l oad . As soon as Tom d emon strated loss
(low
load,
high
repetitions)
tra i n i n g .
Tu b in g was a l so progressively u s e d w i t h more a n d
of con trol (a ltered movement p a tterns, a ltered muscle
more
in
contraction pa tterns any where in the kinetic c h a in but
pro prioceptive neuromuscular facil itation (PNF) pat
espec i a l ly at the knee or more prox im a lly in the lum
ter n s a nd o b l ique movement, as we U as resistance in
bopel v i c-hip stabi l izers ) , t h e exerc ise was stopped .
� J -
fu nction a l
activ ities .
such
a s resis tance
REASO N I N G D I S C U S S I O N AN D C L I N I C AL REASO N I N G C O M M E N TA RY
With p a i n asse s s m e n t for m i n g a s ign ificant
(relative to what wo u ld norm a l ly be expected ) , care
component to the p rogressi o n of re h a b i l i tation
had to be taken when conSid ering the nu mber o f rep
for t h i s patient, can you com m e n t on the
e titions and progress i o n in the re habilita tion pro
d i ffi c u l ties that can a r i se when the athl ete does
g ramme so tha t the ' progression e nve lope' was not
not accurate ly report the onset or seve rity of
p us hed too far. Continual closely supervised m o n i tor
pa i n ! Were there any pati e n t- i n d u c e d
ing enabled the cl i n ician to keep w i t h i n an acceptable
re habi l i tation problems w i t h t h i s pati e n t, s u c h
envelope of progression .
a s i n a c c u rate pa i n reporti ng or ta k i ng of analges ics, that res u l te d i n h i s p rogram m e b e i n g advanced too q U i c k l y !
• C l i n i cal The
reaso n i n g c o m m e n tary
c li n ici a n ' s
recognition th at pain i s
a
di ffere n t
and unique experience for each patien t a n d should
• C l i n i c i an 's answer
be a c c e pt e d as such is evident here. He does not
Because of Tom ' s l ow pain tolera nce, the pain ' scale'
' j udge' the patient or discou n t his pain experience
h a d to be adj usted downward . Also, a n u nderstand
a s non - ge nu i n e Rather. the ' p rogression envelope'
ing o f the di fference be tween the pain of inj ury and
i s adj u sted for this p a r t ic u l a r patien t while taking
p a i n o f ac tivity h ad to be determ i ned and the differ
care not to rei n force the u n he l p fu l belief that pain
.
ence had to be u nde rstood by Tom . In t h is case,
necessarily equals harm.
To m t r u ly fel t the pain b u t w i th h i s tolerance so low
pred i spose to chronic p a i n .
B#i'iUN*"bhbB9"Nii _ • Stage
6
a
yel low f1ag th a t can
limi t i n g factor t o r a n ge w a s n o w felt t o be t h e tight capsule rather than muscle we akness. The therapist fel t the tissue healing was suffiCien tly prog ressed that plastic stretching to in crease the r a n ge of motion was
Five weeks after the su rgery. it was decided by the
the best route to follow w i t ho u t d isru pting the healing
physical therapist that as much ra nge of motion as
tissue. In order to d o this. the knee was placed so the
could be accomplished by doing ac tive exercises had
foot rested on a padded bar with the knee itsel f not
been accomplis hed , and therefore plastic s tre tch i n g
supported. A 6 1 b ( 2 . 7 kg) weight was applied to the
( t herape utic creep) of the tiss ues was instituted. T h e
knee along wi th hydrocoUator p a c ks and a 1 5 m i n ute
end-feel was sti l l a t i s s u e stretch (capsula r) , b u t the
stretch was instituted (Fig.
Copyrighted Material
1 2 . 6 ) . To accomplis h
1 2 M E D I A L C O L LAT E RA L L I GAM E N T R E PA I R I N A P RO F E SS I O NA L I C E H O C K E Y P LAY E R
negative psychological overlay a n d d i fficu l ty sleepi n g . Tom ' s fru strati o n w i t h his progress. wh ich i n real ity was exce llent. was a l most pa lpable. It was eve n tua lly hypothesi zed
that
his c a rd iov ascular fi tness pro
gramme was crea t i n g major fa t i g ue prob l e m s fo r Tom . This was later s hown to be t r u e as Tom m a d e even better prog ress w i t h his k n e e re h ab i l i t ation when h e c u t back h i s fi tness p rog ra m me. T here w a s a l s o a c e r t a i n psyc l1010gical overl ay o n h o w we l l t he athlete fe l t he was im prov i n g . how q uickly he would get back a n d w h a t e ffect the i n j u ry wo u l d have o n his perform ance. This p a r t i c u l a r a th lete was the top ath F i g . 1 2 .6
lete and o n e o f the l eaders on the hockey team: there
Plastic stretc h i ng ( therapeutic creep ) of
fo re, c o n siderable pres s u re was being put o n h i m
poste r i o r knee structu res. Note hotpacks a ro u n d knee
( both by h i msel f and t h e tea m ) t o re t u r n t o p l ay a n d
a n d weight applied o n top.
also t o pe r fo r m a t a very high level when h e retu r ne d . A t this stage, t h e fitness programme ( co n tro l l ed by therapeutic creep o f col lagen tiss u e , a s low prog ressive stretch shou ld be i n stit u ted l astin g 1 5- 3 0 m i n utes for maximum effect (Ko ttke et a1. . 1 9 6 6 : S apega et at. , 1 9 8 1 ) . Stretc h i n g fo r less t h a n 5 m i n u tes is unlikely to have m u c h permanent effect on the collagen tissue. Fifteen min utes was ch osen because of Tom ' s discom fo rt le vel a fter 5 m i n u te s . Maximum load when doing p l astic stretch ing s h o u ld be 8- 1 0 Ib ( 3 . 6-4 . 5 kg) (Kottke et al . . 1 9 6 6 : Sapega et a l . . 1 9 8 1 ) . By heating the tissues. therapeutic creep is more easily a c h ieved . Tom was able to tolerate t hi s very wel l fo r the ftr s t 5
minu tes a n d then fe l t the stretc hing become more a n d more uncomfo r t able fo r the rem a i n i n g 1 0 m i n u tes. With i n five treatments, sign i fic a n t improvement in ran ge of motion was n o ted , "vi. t h fu l l extens ion range o f motion and a normal tissue stretch end-feel accom plished w i t h i n
2 week s . At the same time, l1ex ion
ra nge of motion h a d v irtu a.lly returned to normal t hrough the exercise programme wi thou t p l astic s tretc h i n g .
• Stage
t h e team fitness cons u l tant at a n o th e r locati o n ) was fu lly i n tegrated into the knee reh a b i l i tation pro gramme, w i t h the phys i c a l thera p i s t h a v i n g fi nal say a s to what Tom wou l d be allowed to d o in b o th the fi t ness a n d the rehab i l i tation programmes. To m had t b e seat at a n o r m a l l e v e l while u s i n g t h e bicycle ergome ter and was cycl i n g for 30 m i n utes . The i n te n S i ty ( l o a d ) p l aced on the bicycle ergometer was now deter mined by the desired cardiovascu l a r effect rather th a n the stress o n the knee. Tom began by worki n g at 7 0 % o f his m a x i m u m heart r a t e fo r th i s effect a nd worked u p t o 8 5 % . O t h e r exercises c o n tinued i nc l u d i n g quadriceps exercises, using the b a l a nce m a c h i ne, b a l a ncing exerc ises. a n d more fu nctio n a l exercises such a s s l o w j ogg i n g fo r ward and backward , c a r i o c a exercises ( ru n n i n g side ways with cross-over step s ) , pylon r unning ( s l ow) fo rwards a n d backwards ( r u n n i n g a r o u n d py lons so person turns r i g h t and l e ft ) . figure-8 r u n n i n g ( s lo w ) .
and ascend i n g / descend i n g sta i r s . D u r i n g t h i s period . To m was fi tted with a custom fu nctio n a l brace. which h e began we aring duri n g his exercise p rogra m m e in
7
order to become used to it, a s h e would b e wea r i n g
By 6 weeks. Tom bega n doi n g Cy bex isokinetic exer
t h is b r a c e whe n he returned t o competi t i o n . As t h e
cises a t slow s peed settings of 3 0 . 6 0 . 90 and 1 2 0
l e g d i mensions a r e u s u a l ly a l tered fo llowin g i n j u ry, i t
degrees per second maxim u m
10
is common practice for t h e medical tea m to fi t t h e a t h
depend i ng on fat i gue a nd symptoms ) . A t this time,
( t h ree sets o f
lete w i th a n 'off-the-shel f ' brace initially to p rotect the
Tom wou ld h ave some good days and some bad d ays
knee because i t i s less expe ns ive. Once the leg d i me n
depen d i ng on how hard he pushed both his exerc ise
sions a r e close to norma l (compared wi th the u n i n
for his knee and his cardiovascul ar fitness. A ' b ad day'
j u red leg) , a custom brace is fitted for the athlete to
experience for Tom was the knee not fee l i n g as good as
retu r n to competitio n . Com mon ly this brace is then
the prev ious d ay. with some aching combi ned with a
wor n at l e a s t u n t i l the end o f the s ea son . The custo m
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C L I N I CAL R EAS O N I N G I N ACTIO N : CASE STU D IES F R O M EX PERT MAN UAL THERA P I STS
brace was a br a c e d e s i g n e d by a l o c a l or thotist to pro v i d e medial and l a t e r a l protection to the knee.
• Stage
• Stage
9
By the e i g h t h we e k , sk a t i n g was more r i gorous and
Tom was us i ng the exerc ise m a chi n e s at h i g her l evels
8
and h i g h er wei g h ts . Tom's skill l ev e l o f s ka ti n g even
By th e seventh week, in a d d i tion to the above pro g r a mm e Tom b e ga n s k i p p i n g and d o i n g h i g h - s p ee d .
C y bex i so ki n e t i c ex e rc i s e s ( s p e e d s : 1 2 0 . 1 8 0 , 2 4 0
degrees per sec o nd ; 1 m i n u t e exerc ise, 1 m i nu t e rest. t h ree repetitions a t e ach s p e e d ) for endurance. Also,
b a sed o n To m's ability to control h i s knee motion b o t h in c l o s e d and o p e n kinetic chain activities, more di ffi c u l t kinetic chain activ i ties were i n stituted , s uch a s
on e-le gged h o p exercises forward s , backwards , t o t h e
( + ).
s i d e , a n d aro u nd a c r os s
At the end of 7 weeks,
in a dd i ti o n to the above programme that continued,
Tom h ad d e m o n s tr a t e d a d e q u a t e str e n g th
c o n t ro l
,
.
e n d u r a n ce a n d ag i l i ty i mprovements to b e gi n skati ng. His i n i tial skati n g e p i so d e was 15 mi n u te s of e a s y
skating w i t h no eqUipmen t exc ept skates, e l bow pads, helmet, g l o v e s and stick. As T o m improved, the time, ,
s pe e d a nd difficulty of the sk a t i ng exercises were increase d . Initia lly Tom did not have a p u c k to handle o r shoot , b u t a p u c k was i n clu d e d a s he progressed to
make t h e activity more complex . Because Tom w a s
a
h i g h ly s k i l led h ockey p l ay e r, it was n e c e ss ar y t h a t th e
p hysic a l ther a p i st be present fo r all the i n itial s k a t in g sessions as Tom had a very st r o n g t e n d e n cy to want to do too much at each session . C o nseq u e n t l y, his acti v i ty
had to be very carefully controlled . Skating d r i l l s at the
at t h i s stage was better t h a n many p r ofe SSi o n a l
h oc ke y players a n d he had to be controlled to ensure he d i d not overstress the knee. S k i p p i n g a n d hopping were c on ti n u e d a s was sta ir work . Because of t h e con
trol . strength a n d e n d u ra nce demons trated by Tom d ur i n g skating and d u ring his e x erc is es p l y om e tr i c s ,
were i n s t i t u t e d to i m p r o ve fu r ther the reactive ab i l i ty of t h e lower limb n e u romusc u l a r sy s tem Acti v i ties .
i ncl uded j umpi ng o n a n d off a b e n c h a nd j u mping over a bench .
By t h e end of
8 wee k s , To m
wa s
skating up to 4 5
minutes a n d the bicycle p ro gr a m me varied from one
d ay to the next: one d ay bei n g an endurance ( a e r o bi c ) prog ramme a n d the next day be i n g a s p r i n t ( a n a e ro
b i c ) prog ramme. This enab led training or t h e two p r i m ary energy systems ( 8 0% a n a e r o b ic and 2 0 % aer o bi C) u sed i n i ce hockey, as wel l a s i mprov i n g the aero bic system t o fa c i l i t a te re c o ve ry fo l l o w i n g exer cise. T h r o u g h o u t the p r o g r a m m e To m received treat .
ment 6 d a y s p er wee k on a o n e to one basis w i th the p hy s ic a l th era p i s t This high leve l of t r e a t m e n t v i sits .
is com mo n for profess i o nal
athletes
where fu n d ing is
not a n i s s u e but where g e t t i ng a highly t r a in ed and
paid a t h l e t e b a c k
t o p l ay i ng his sport i s o f prime
i mp o r t a n ce.
e a r ly stage i ncl uded skati n g h ard between the blue l i n es ( s tra i g h t a h e a d ) and coasting around the e nd s
( c u rve s ) , figure- 8 s k a ti n g crossing the 'T' a t cen tre ice ,
• Stage
10
(ska tin g forwards , backwards and s i d ewa y s within
By the e n d o r 1 0 weeks, Tom was c lear e d to sk a te with
the cen tre ice circle) , as we ll as just s ka ti n g w i t h t h e
the team i n p r ac tic e This is cl a s s ed as a controlled
p u c k d o i ng v a r i o u s s katin g dril ls (Fig. 1 2 . 7 ) . In ad d i
sk a tin g with control led acti v i ty as the a t h l e t e go e s
tion, Tom co n ti nu e d w i t h h i s skippi ng ( fo rwar d a nd
thr o u g h s p e ci fi c passing a n d s k a t i n g drill s a l on g with
b a c k w a r d ) , rid in g the b ike fo r 3 0 minutes, cl i m bin g stairs, and
wo r kin g
on the exe r c i se m a ch in e s
.
.
the r e s t o f the tea m , b u t th er e is no bo dy contact. If the athlete is a l l owed to retu r n to practise with the team,
h e is ex p e c ted to do e ve ry t h i n g other tea m m e mb e r s do, except for b o d y c ont a ct I n i ti a lly, the athlete is not .
allowed to scrimmage ( p l ay a contTo l led ' ga m e ' with other p laye r s )
unti l t h e med ical
team is sure the ath
lete h a s no p robl em with tea m drills. If he h as no prob l e m s with the dril ls, as w a s the case w ith Tom , he is
a llowed to scrimmage. If he has no p r ob le ms with
scrimmaging and tests (Cy bex tes ts, fu nctional tests , phy s i c a l exa minatio n ) show no p r obl e m s , the ath lete Fig. 12.7
Player d oing pylon skating as p art of his
functional retraining.
i s a ll owed to return to c o m pe titi o n if he feels he is
r ea dy By the twelfth week Tom re tu rned to play. .
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,
1 2 M E D I A L C O LLAT E RAL L I G A M E N T R E PA I R I N A PRO FES S I O N AL I C E H O C K EY PLAY E R
R EAS O N I N G D I S C U SS I O N A N D C L I N I CA L R EAS O N I N G C O M M E N TA RY
D
Can yo u c o m m e n t on why you th i n k t h e
I
fl e x i o n i m p roved w i th active exe rc i s e wh i l e
u s e d to l e s s e n s u c h pressu res on the th e rapist a n d the ath l ete ?
t h e exte n s i o n re q u ired pass i ve stretc h i ng?
• C l i n i ci a n 's
• C l i n i c ian's answe r W hy flex i o n req u ired no
p l ast ic s tretc h i n g w h i l e
extension d i d i s d i rtku l t t o a sc e r ta i n . I t m a y have been because the b a ms tri n gs demon strated greate r s treng th
fo l l ow i n g s u rge ry. bei n g
a bl e
prog ressively t o
' s tretc h ' o r stress t h e a n terior c a p s u le m o r e ma rked l y
.
strcssed t h e MeL as much ( i n flex i o n , t h e a n terior fl brcs o f the l igament a r e pri m a r i l y stressed ) , a l low i n g t he a t h l ete to wo rk Alte r n a tively. n ex i o n m a y n o t h ave
o n nexion to a g reater d e g ree with less d i s c o m ro r t .
an swer
It i s common practice with the team invol ve d t h a t the physica l thera p is t i s t h e primary c a re g i v e r a n d determines t h e course o r treatme n t . in conj u n c t i o n w ith t h e p hYSi c i a n a nd team a t h le t ic tra iner. in s i t u a
tions w h e n physi c a l t hera py i s req u ired a rter surge ry. I nitial ly. there was
a
b r e a k d ow n i n c o m m u n i catio n
w i t h the fi tn ess pers o n bec a u s e t h i s was t h e fi r s t ye a r s uc h
a
per s on w a s a v a i lable to the
tea m . T h e s u rge o n
w a s rea d ily ava i l able i r t h e physic a l therapist h a d a ny ques t i o n s . since the s urgeon . phys i ca l therapist
imd
Iltness p e r s o n a t tended a l l h o me hockey games ( aver
IJ
What gu i d e d yo u r d e c i s i o n t o adj ust the
age o f one to two per wee k) . T h i s a l lowed the s i tuat i o n
p ri n c i pa l aim of the b i cyc l e e rgo m eter exe r c i s e
t o b e cont i n u ally reviewed and discussed w i t h t h e
fro m o n e b a s e d on t h e local stress p l a c e d on
a thletic tra i ner. c o a c h a n d genera l manager ( i r neces
t h e knee to o n e of card i ova s c u l a r fi tn ess ?
sary ) . To m was seen by a l l people i nvolved. A l t h o u g h
a s soon value to t b e t e a m .
there was pressure to return To m to p l ay i n g as p ossi b le beca use of the p l ayer s '
• C l i n i c i an 's an swe r
there was n ever so
Once the po i n t was reac hed when Tom ' s k n e e wa s able to
stand the stresses o r normal closed kinetic
much press u re that he was fo rced
to return too e a r ly. With this tea m . the h e a l t h o f the ath lete is of p r i m a ry importance.
chain activity, and because no symptoms resulted from these stresses , it was fe lt t hat he could do normal cardiovasc u l a r tra i n i ng using both legs . Up to t h i s poi n t . Tom was using an u p p e r b o d y ergometer for h i s card iovascu l a r fi tness.
What was you r c l i n i ca l reaso n i ng a n d s c i e n tific rati o n a l e fo r i m p l e m enting plyom etr i c exe rcises at the eighth week (stage 9) ?
There seems to be a n u m b e r of h e a l th
• C l i n i c i a n 's
p rofes s i o n a l s i nvo lved i n th i s ath l e te'S
an swe r
rehab i l i tati o n . Co u l d you c o m m e n t on what was
As plyo metrics is a h igh s tr e ss activity t h a t req u i res
req u i red of th e thera p i s t in h i s i n t e r p rofe s s i o n a l
good control. it was not i nstitu ted until Tom could
co m m u n i cati o n w i t h t h e oth e r h e a l th
d e mon strate satisfactory control in fu ncti o n a l activ
-
p rofessionals, the coac h , m a n ager, tea m own e r,
i t i e s . The purpose o f the plyometric exerc i ses was to
etc . ? H ow does this i m pact on t h e d e c i s i o n s
e n h a nce the neuro muscu lar system by i m provi n g its
m a d e b y t h e t h e ra p i s t a n d h o w can r i s k of
reactive abi l i ty thro u g h combining speed of move
confl i cting i nfo rmati o n be m i n i m i zed when so
ment ( doin g the bounce in the j u mp q u ickly ) and
m a ny peo p l e are i nvo lve d ? T h e re is clearly
strength
p re s s u re to get the p l aye r back to his sport as
involve s eccentric l a n d i n g .
( l i fting
his
body
we ight) .
The
activity
act i vati n g t h e s tretch
soon as poss i b l e . Can you also comment on
retl e x . and concentric push o fr. T h i s acti o n o f landi n g
h ow certa i n strateg i e s , such as the s u rgeon
on t h e toes a nd p ush i ng o ff q u i ck ly is u s e d w h e n skat
ta k i ng the res pons i b i l i ty of l i a i s i n g with
ing and helps to improve reaction time, wh ic h is
ma nage ment o r oth e r p rofe s s i o n a l s , m ay be
important in a fast mov i n g sport s u ch a s h ockey
.
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C L I N I CA L R EASO N I N G I N ACTI O N : CASE STU D I ES F R O M EX P E RT M A N UA L T H E RA P I STS
II
Would you describe what precautions we re
decisions or being a ffected by such decisions ( i n this
observed during the reha b i litation for thi s
case the coach and gen e ra l manager ) . In other
patient?
p atie n ts significant st a ke h o lders may include family. .
e m p loyers and fu nding bodies . The benetits of s h a ed r
• C l i n i cian's an swe r
decision making
Tom ' s tre atment was d e s ig n e d to 'push the envelope'
are i ncreasingly being recogn ize d
across the hea lth p rofe ss i o n s ( Ersser a n d Atkins,
of he al i n g a n d prov ided no adverse signs and symp
20(0) and d e vel op i ng expertise in manual t h era py
toms a p pear e d he was c ontin u a lly pushed . Red flags.
requires that practitioners acqu ire these skills.
,
,
b a ck o ff '
The st rateg i c i n trod u c t i o n o f plyometric exer
o n tre a tment included increased pain. p er s is t en t sti ff
w h i c h led the p hy s i c a l thera p ist t o m o d i fy or
cises h igh l ig h ts the specilk ity of tra i n i n g req u ired
'
,
ness and strength plateau ing. Other factors that c ou ld
when wo rki n g w i t h hig h- level a t h letes such
h ave been incl uded but were not factors here include
patien t . Even wh en postoperative protocols exist
t he
swe l li ng i n the j O i n t or tissues. c on t i n u ed m u scle
(Le.
b u rn i n g
a pp roach to re h abilita t i n g
.
onset
of
crepi tus
a nd fa sciculations or
surgeon's
and
re b a b i l i tation
as
this
team's
tbis type o f repa ir).
this
c a s e n icely h i g hl igh t s how individ u a l p a t i e n t treat
cramps in muscle.
ment selection and prog ression decisions are b ased on t h a t patien t's p ar tic u l ar presen t a t i o n a n d bis
• C l i n i cal
response to treatme n t s . as determined by tbe
reaso n i ng c o m m e ntary
on goi n g reassessment of spec ilk phys ical impa ir
In re s po n se to q u e st i on 3, the c l i n ic ian has p rov i de d a nice example of collabora t i ve reasoning in ac t ion
.
m en ts and fu nction a l ind icators. Physiotherapy
ex p er t i s e in t h i s setting requi res s p eci a l su rger y
Collaborative reason i n g . as p or trayed in Chapt e r 1 .
a n d sport-specillc knowled ge in order to i m p l e
is the shared decision m akin g between patient.
ment a n d progress the optimum
health care p rov id er s (in this case t he p hys i c al ther -
apist, orthopaedic s u rgeo n and the ath letic tr ai n e r ) and relevant others
c o n tr ib uti ng
to management
Outcome
s t rate gies for maxi m u m speed of recovery with o u t
. compromising t h e h e a l i n g tissues or i n c u rring
a
r i s k of recu rrence.
but Tom felt he could o v e rco me these t h in g s and com pete w i th n o d i ffic u l ty.
At 1 m o n t h fol lowing Tom ' s return t o play ( 1 6 weeks) . he s til l had not reached his full po te n tia l foll owin g the
i nj u ry. This was evident to
rehabilitation
b oth
It
m u st be remembered that
the maj o r i ty o f athletes are y o u n g . ver y h ea lthy and
very good at t heir sport. with h i gh expec tations espe
the coaches and the
Ci ally in pro feSSi o n a l sport. To receive a maj o r i nj u ry
medical team . Tom was not performing at the level that
o lten ma k e s them face their own mortality, and many
he was at before th e inj ury. Al tho u gh he could skate as fast. he was ten ta tive in his p lay making and showed h esita tion when there was the potential of b o d y con
people h ave d i ffic u l ty dealing with t hi s a l o ng with
tact. Tom stated that he felt the knee was fme al th ough he stUI h ad some ' twinges' in the Imee when p l ayin g . As
a
pre c a u ti on against swelling or pain . To m received
ice to the lmee for 1 5 m inu tes after every practice. game or worko u t . From the begi nning. he was told by tbe p hy s i c a l th erap i s t and the orthopaedic sur ge o n that i t wo u ld be a long-term process and that the heal i ng wo uld probably tal<e at lea s t a ye ar to be c om p leted ,
t heir i nj u ry Tom fo und that a l t h o u g h h e was ab le to ska te and play he was n o t able to bring his level of play up to t h a t he h a d prev iously achieved . al t ho ug h there was i m p r ove m ent Psycho logically this was very hard fo r To m , but the the rapi s t conti nued to work with him to try to en s u r e that he wo u ld r e t u r n to hi s fu l l level of a b i l i ty. At 24 weeks To m had a l most returned to h is fu l l pote nti al . Howeve r. a spo r t psy c hologist was also e n listed to help h i m to deal with h i s apprehension a nd fr ustra t i o n .
Copyrighted Material
.
.
.
1 2 M E D I A L C O L LAT E R A L L I G A M E N T R E PA I R I N A P RO F ES S I O N A L I C E H O C K EY PLAY E R
� J _
D
R EAS O N I N G D I S C U S S I O N A N D C L I N I C A L R EAS O N I N G C O M M E N TA RY
I n h i n d s ight a n d w i th the pres e n c e of the early i n d i cato rs of psyc h o l ogical fa ctors, do yo u th i n k
• C l i n i cal
that t h e spo rts psyc h o l ogist s h o u l d h ave been
The key word from a reasoning perspective i n this
co n s u l ted soon e r i n th i s parti c u l a r cas e ?
answer is ' reflection ' . It is often incorrectly
that experts have such good knowledge
• C l i n i c i an 's an swe r
assumed a n d vast
experience that they do not make ' mistakes' . Every
On re n ectio n , it pro b a b ly wo u ld h ave been of benefit to consu l t a s ports psyc h o l ogist e a rlier in the rehabi l i ta li on programme. O n e th i n g t h is case has i l l ustrated to me, n ow t h a t I watch more cl osely fo r these a d verse psyc h o logical re action s . is how fragi le i s the psyc he of many a t h l etes . wh ich in m a ny ways i s surprising given the h i g h demands a nd someti mes viciousness o f con tact/co l l ision sports . At hletes. probably more t h a n most pa tien t s , require
reason i n g co m m e ntary
a
great deal of posi tive
rei n fo rcemen t o n how they are prog ressing. The fe ar
exper t repre se n ted in t h is book would certainly dis count this assumption. Experts do make mistakes . but because they te nd to possess supe ri or meta cog nitive ski l ls
,
including continual r e flec t io n
,
th ey
learn from their patient experiences, continually bu ilding and refining their k n ow l edge and ski lls for use with future patients. Experts have superio r knowledge, not superior memory. They
have supe
rior knowledge because their reasoning is o pe n minded, c r i tic al
and reflective.
of losi ng their liveli hood ( a n d sometimes high sala ries) is very re a l to them.
• Refe rences Ersser. S ,J. a n d A t k i n s . S.
( 2 000 ) . C l i n i c a l
re aso n i n g a n d patien t - c e n tred c a re.
I n C l i n ical Reaso n i n g i n the Hea l t h Profess i o n s 0 . H i ggs a n d �,! . Jones. cds . ) pp. 6 8 - 7 7 . Oxford : Bu tterworth-Heineman n . Kenn edy, r C . ( 1 9 7 9 ) . T h e Inj ured Adolesc e n t K nee.
B a l timore. M D :
W i l l i a m s & Wi l k i ns.
•
D . L . a n d Ptak. R.A. ( 1 9 6 6 ) . The rationale f o r pro l o n ged
Kottke. p.r . Pa u l ey.
Reha b i l i t a ti o n . Ed i n b u r g h :
Ch u r c h i 11- Li v i ngsto n e . G rifr m , L . y. ( 1 9 9 5 ) . Rehab i l i tation o f the Inj u red K n ee. Lo ndon: Mos by.
R.A. and Bu tler, R . A . ( 1 9 8 1 ) . B i o physical
s t retc h i n g for cor rection of s bor teni n g
fac to r s i n range of motion exerc ise.
o f connective t i s s u e . Arch ives o f
P hy s i c a l Sports
P hysical Med i c i n e a n d Rehabil itati o n . 4 7 . 3 4 5-3 5 2 . Muller. W. ( 1 9 8 3 ) . The Knee: Form, Fu nction a nd Ligament Reconstruction . Berl i n : Springer-Verlag.
F u rt h e r read i n g
El l enbec ker. T.S . ( 2 0 0 0 ) . Knee Ligament
Sapega. A . A . . Qued e n feld. T. e . . Moyer.
Hughsto n . r. C. ( 1 9 9 3 ) . K n e e Liga m e n ts :
Mos by. W. N. ( 1 9 9 1 ) . Ligame n t a n d
I n j u ry a nd Repai r. London: Scott.
Ex tensor Mec h a n i sm I nj u ries o f the l(n ee. Lo n d o n : Mos by:
Copyrighted Material
Med icine 9. 5 7- 6 5 .
CHAPTER
Patellofemoral pain in a professional tennis player
13
Jenny McConnell
�
S UBJECTIVE EXA M INATIO N
A 27-year-old professional tennis player presented
This was because the magnetic resonance imaging
with a o-month history of gradually worsening left
(MRI) scan showed a bone bruise on the lateral side of
knee pain. The player complained of anteroinferior
the trochlear notch. The enforced rest on crutches had
pain. as well as lateral knee pain. The lateral knee
resulted in marked atrophy of the quadriceps muscle
pain. which only became a complaint 6 weeks ago
but had not changed his inferior pateiJar symptoms to
when the player changed orthotics. was extremely
any great deg ree. a lthough the lateral symptoms had
severe . particularly when
the knee
was flexed in both
subsided. He was now very depressed as his tennis
the stance and swing phases of gait. The pain was so
ranking was sliding and his knee was not improving.
tournament.
He was unsure of his future and was contemplating
It was less intense at the time of presentation. but he
retiring from tennis on medical grounds. but this was
had not been stressing the knee at all as [or the past
not his preferred option.
severe that he was forced to pull out of a
month he had been
� j .
non-weight bearing
on crutches.
RE ASO N ING DIS C U S SION AND C L I N I C AL REA SONING C O M M E N TARY
From the information elicited at this early stage. were you at all able to recogn ize a clinical pattern in his initial presentation? What were your principal hypotheses for the two pains. and were there any other potential sources that you considered and planned to test through further examination?
was suggestive of an iliotibial band (ITB) friction syndrome. because the player was complaining of the lateral knee pain during flexion. even unweighted flex ion. of the lmee. In the l1exed position of the knee. the ITB is under tension. and if tight it wUI rub over the lat eral femoral condyle. causing a tendonosis of the ITB or
an
inl1ammation of the intervening bursa (Brukner
• C l in ic ian 's an swer
and Khan. 1993). Additionally. the change in orthotics
From the initial part of the history. it was clear that the
structures in the lower extremity and place more stress
may have been sufficient to alter the balance of the
athlete had two different types of knee pain. which
on the ITB. If the orthotic is made from a rigid or semi
could possibly be related. The more recent lateral pain
rigid material. then shock attenuation at the foot may
194
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13 PATELLOFEM O RA L PA IN I N A P RO F ES S IO NA L T ENNI S PLAY E R
b e poor. particularly i f the p ati ent has a stiff rearfoot
1998).
(Grelsamer and McConnell.
This decrease in
Therefore. chondromalacia is a less likely diagnosis i n this case.
shock absor ptio n places incre ased stress on the distal end of the ITB. as the internal rotatory force of the
tibia. which should occur with knee flex ion . is blocked by the distal external rotatory force created by the
• Cli ni c al reasoning com m e ntary The early formulation of hypothe ses relating to the
orthotic. T he long -stan ding inferior pain could be
source of the
caused by a patellofemoral problem or patellar ten
poten tial
donosis. More information fr om the history about the
orthotics) is evident in t h is response. In partic ular.
pains (e.g.
contributing
patellar te ndonos is)
( e .g.
factors
change
a nd
in
behav i our of the pain is required before a provisional
the identification of ini tia l cues ( th e location of the
diagnosis can be formulated.
lateral pain in an elite
The MR1
athlete
a nd
its behaviour)
fracture .
appears to have tr iggered the recognition of a famil
Whether there was underl yi n g chondromalacia and
iar clinical pattern. i.e. ITB fric tion syndrome.
whether it was contributing to the patient's symptoms
Diagnostic
could not be de fin itely determined at thi s stage. The
l argely d epen d ent on previous clinical experience
state of the articular cartilage can only be assessed
with similar presentations and is. therefore. not usu
with a T rweighted image on MRI. sO it is poss ible the
al ly an important feature of the clinical reasoning of
had
ruled
out
a
stress
accuracy
in
patter n
recognition is
patient had some chondral degeneration. w hic h is
nov ice practitioners but is heavily re lied upon by
common in te nni s players. However. recent evidence
experts. such as in this case. It is important to high
has suggested that articular cartilage degeneration is
light that the clinician has also drawn on informa
usually asymptomatic (Dye et al. .
tion from
1998). Nonetheless.
symptoms a clin ician would need to be aw are of to
knowledge gained
indirectly trom the
li terature and that this has been effectively inte
determine the presence of articular cartil age degene r
g rated
ation include swelling and l ocking . as well as pain.
own person al clinical experiences.
with knowledge di r ectly gained from her
The inferior knee pain did not keep the patient awake
medication he was t akin g ) did not have any effect on
at night. but it did cause him con siderable discomfort
the symptoms. He had never taken steroids. nor
when he was standing and going up and down stairs.
experienced any symptoms in the hips. feet. lumbar
The knee did not lock. click or give way. but it had been
spine or any other joint. T his "lAlas his first episode of
swollen . The swelling was mostly infrapatellar. but
left knee pain. He had experienced medial pain in the
he did occ asion ally notice minor joint effusion after
right knee 5 y ears ago. which improved w ith the fit
playing. When the player was first aware of his knee
ting of l1exible orthotics in his shoes. The orthotics
symptoms 6 months ago. he had been play i ng on grass
were prescribed for his forefoot va lg us d e formit y.
and was running back from th e net to reach a high
which caused excessive pronation at mid s tance . He
backhand smash. He won the point. but as he made
used flexible orthotics until recen tly . when a computer
contact with the bail he felt a pinching sensation distally
gener ated pair was mad e . It was after this that the left
in his knee. That evening the knee was slightly puffy. so .
lateral knee p ain developed.
he iced it and sought some treatment. The treatment
His general health was good with no rec e nt weight
consisted of elec trotherap y (ultrasound and in te rferen
loss. and the only surgery he had und er go ne was an
tial curren t ) . as well as quadriceps muscle stretching
appendectomy 3 y ears ago. The p la in r adiog raph of
and s trengthening .
the knee was unremarkable. but the MRI showed a
The quadriceps strengthening
involved straight leg raises and isokinetic leg extension.
bone bruise on th e trochlear n o tch . It was this finding
The Imee initially was only intermittently p ain ful.
but
that prompte d the orthopaedic surgeon to put the
weeks of treatment it had worsened trom being
patient on crutches. However. as the p atie nt vvas not
after 3
painful only when the p l ayer was returning low volleys.
improving and becoming increasingly anxious with
to being painful during aU aspects of play.
each day away from training. the surgeon referred the
Additionally.
the
patient
st eroida l anti-inl1ammatory
reporte d
that
non
pa tien t to m e .
medication (the only
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C LINI C A L R EASO NIN G IN ACTIO N : CASE STU D I ES FRO M EXPERT M A N UAL THE RA P I STS
� I r
REAS O N I N G D I S C U S SION AN D CLI N I CAL REASONING COMMENTA RY
What was your interpretation of the worsening of the athlete's knee pro blem? Did the additional information regarding the mechanism of symptom onset enable you to narrow your hypotheses further regarding the source of the inferior knee pain?
patient's symptoms in so far as the patient was com plaining primarily of inferior patellar not retropatel lar pain. which was the location of the bone bruise. In changed the patient's inferior patellar symptoms at
At this stage, it became clear that rapid ell.1:ension of the knee (retrieving the high backhand smash) produced
initial
The bone bruise may have been incidental to the
addition. being on crutches (rest) for a month had not
• Clinici an's answer the
• Cl inician's an swer
pain and that the treatment may have been
instrumental in worsening the symptoms. Therefore. the most W<ely diagnosis for the tennis player's inferior patellar pain was an irritated fat pad. because it was trig gered initially by a rapid ell.1:ension manoeuvre. mani
all. which would have been anticipated if the symp toms were ariSing from the bone bruise.
D
How did the working hypotheses you entertained influence your planning of the phy sical examination?
fested returning from flexion (returning a low volley)
• Cl i nician's answer
and was also exacerbated by treatment. It is unW<ely
At the completion of the history. the provisional diag
that the electrotherapy part of the treatment was the
culprit.
nosis for the patient's lateral knee pain was ITB friction
but it was possible that the quadriceps work.
syndrome and the provisional diagnosis lor the infer
particularly the strengthening exercises, may have con
ior knee pain was an irritated infrapatellar fat pad.
tributed to the increase in symptoms. The strengthen
Both conditions are usually the consequence of poor
ing exercises emphasized extension of the lmee, which can cause an increase in symptoms when the fat pad is inflamed. Once the fat pad is inflamed, forced extension of the knee, which causes a posterior tilting of the infer
patellofemoral biomechanics. such as a tight ITB. poor pelvic control and excessive loot pronation. The aim of the physical examination was to test further possible sources of the symptoms and to determine
ior pole of the patella as a result of the attachment of
which of the biomechanical variables were contribut
the patellar tendon on the tibia. may further irritate the
ing to the patient's symptoms. so that treatment could
fat pad. The fat pad has been found to be the most pain sensitive structure in the lmee (Dye et aI.,
1998).
At this stage. the dilTerential diagnosis of patellar ten donosis could be largely discounted for three reasons. 1. There had been no reported increase in eccentric loading of the quadriceps during training or match play. Tendonosis is usually provoked by an increase in eccentric loading of the quadriceps muscle. 2. The particular quadriceps exercises given should not have markedly worsened the symptoms as there is less tension in the tendon during knee extension and straight leg raise than during eccen tric activities. 3. The MRI did not demonstrate any degenerative change in the patell ar tendon,
which usually
occurs when tendonosis is present.
II
be directed accordingly. There were several examination procedures of par ticular importance with respect to testing the work ing hypotheses: • the Thomas test, which assesses the tightness of the tensor fasciae latae (TFL). as well as the rectus femoris and psoas muscles • Ober's test. performed in side lying. usually elicits pain when the lmee is flexed and extended from o to
30
degrees if the
ITB
is tight; this is because it
flicks over the lateral femoral epicondyle causing inflammation and pain • when the condition is acute, the lateral femoral epicondyle is often quite tender on palpation and the fat pad is frequently enlarged and when pal pated feels quite 'boggy' compared with the other
What weighting did you place on the MRI finding
side, with the patella buried in the fat pad such that
of a bone bruise?
the inferior pole is difficult to palpate
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13 PATELLO FEMO RAL PA IN IN A PRO F E S S IO NA L T ENNIS PLAYER
• inferior patellar pain is often exacerbated by an active
quadriceps contraction in full extension, as well as during passive extension performed by the therapist.
• Clin ical Following
tendonosis), often an absence of an expected rm din g
.
A plausible pathomechanical hypothesis consistent
with the clinical presentation and with scientific understanding of kn e e pathology lends further
reasoni ng com m entary
weight to the favoured diagnostic hypothesis.
The assessment of the MRI finding of
the
bone
early generation of diagnostic hypotheses based on recognition of initial cues from
bruise demonstrates testing of a diagnostic hypo
familiar clinical patterns, the information obtained
thesis (bone bruise as both source of the symptoms
a
from subsequent enquiry strategies (e.g. the worsen
and associated pathobiological mechanism) with
ing of the problem)
is used to test the competing hypotheses. The picture that unfolds is one in which
other findings from the history (location of pain and
there is growing evidence that supports one hypoth
hypothesis. Consequently, the hypothesis has been
esis
rejected and the main supporting clinical evidence
(irritated
fat pad) and other clinical data that
tend to ne ga te
tEl
the alternative hypothesis (patellar
response to rest), which are found not to support the
(MRI scan) reinterpreted as an incidental finding.
PHYSICAL EXA M I N ATIO N of lmee i1exion when descending stairs, during which
Observati on Examination of the patient in standing revealed an internally rotated femur, tibial varum, an enlarged fat
t he
trunk lateral flexion was even more pronounced.
pad on the lert side, stiH rearroot and compensatory
Passi ve exam i nati on proc edures
midfoot pronation. The rearfoot was deemed to be stiff
In supine lying, the inferior pain was slightly elicited
because the talus was quite prominent on the medial side when the patient was viewed from the front but the calcaneum was straight when viewed from behind. If the talus was prominent on the medial side in standing. the calcaneum should be everted if the
rearfoot had adequate mobility. The left quadriceps muscle, although smaller than the other side, was well dermed. The ITB appeared taut on both sides. The glu teus maximus muscle was well developed, but the glu teus medius muscle was suboptimal in bulk bilaterally. The patient was examined dy namically
on passive extension overpressure of the knee. All other passive movement tests were clear, including i1exion overpressure (straight and with an abduction and adduction bias), McMurray's test for the menis cus, and Lachman and pivot shift tests for the anterior cruciate ligament.
M usc l e l ength tests The TFL muscles were found to be bilaterally tight dur ing the Thomas test. The iliopsoas, rectus femoris and
the effect of muscle action on the static mechanics, as
TFL muscles may all be tested using the Thomas test
well as to reproduce symptoms. The least stressful activ
(Hoppenfeld, 1976; Kendall and McCreary,
ity of wallting, which did not reproduce any symptoms,
perform the Thomas test, the patient stands with his
1983). To
was examined ftrst. There was minimal knee i1exion evi
ischia touching the end of the plinth. One leg is pulled
dent at heel strike on the left side during walking. The
up to the chest to i1atten the lumbar lordosis, and then
patient also demonstrated increased trunk side Ilexion
the patient lies down on the plinth keeping the Ilexed
on the left side during the stance phase of gait, often
leg close to the chest. The other leg should be resting
suggestive of wealmess of the gluteus medius
and per
such that the hip is in the neutral position (i.e. on the
haps more proximal weakness of the trunk In this case,
plinth, at the same width as the pelvis) and the knee
it was probably poor gluteal control contributing to the
should be i1exed to 90 degrees. If the hip is in the neu
problem rather than proximal trunk wealmess, as the
tral position but the knee cannot be i1exed, then rectus
patient was regularly doing Pilates exercise classes as
femoris is tight. If the hip is i1exed but lying in the
well as abdominal strengthening activities in the gym.
plane of the body, the iliopsoas muscle is tight. If the
The inferior patellar pain was reproduced at
hip remains l1exed and abducted, then TFL is tight.
60 degrees
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.:
C LINIC A L REASO NING IN ACTIO N: C A SE STU D I E S F RO M EXPERT M A NUAL THERAPIST S
Lack o f flexibility o f T FL can b e further conflfmed in side lying by Ober's test (Brukner and Khan, 1993: McConnell, 1996). The Thomas test needs to be per formed on both legs so a comparison between legs can be made. The other muscles acting around the knee were more than adequately flexible. In fact, the ham string muscles were almost too flexible, with a straight leg raise of 100 degrees bilaterally.
Flexibili ty of l ateral structures The side-lying position was used to assess the l1exibility of the lateral structures. notably the lateral retinacu lum (superficial and deep fibres) and the ITB. To test the superficial retinacula structures, the knee was Ilexed to 20 degrees, from where the patella
was
moved pas
Sively in a medial direction. The lateral femoral condyle was not readily exposed, indicating the superficial reti nacula fibres were tight. The deep fibres were tested
Pate l lar posi ti on
with the patient in the same position. The slack of the
Although determining the position of the patella
anteroposterior pressure was applied to the medial bor
relative to the femur has been found to be somewhat
der of the patella. The lateral border did not move freely
unreliable when performed as an isolated procedure
away [rom the femur, which indicated that the deep
glide was taken up in a medial direction and then
(like most manual palpation tests), it still remains an
an
fibres were also tight. Tightness of the ITB was further
important part of the examination process and can be
conflfmed by Ober's test (McConnell. 1996).
used to help to guide treatment choice (McKenzie and
test. the underneath hip and lmee are Ilexed to stabilize
Taylor, 1997; Potter and Rothstein, 1985; Watson et al.. 1999). The left patella was laterally tilted and displaced, with the inferior pole tilted posteriorly into
In
this
the pelvis. while the knee of the upper leg is flexed to 90 degrees and the hip is abducted. externally rotated and slightly extended. The thigh remained abducted
the fat pad. This was determined by examining the
when the leg was released, indicating tightness of the
patellar position relative to the trochlea. An optimal
band (McConneLl. 1996).
patellar position is one where the patella is parallel to the femur in the frontal and sagittal planes, and the patella is situated midway between the two condyles when the knee is flexed to 20 degrees (Grelsamer and
Other examination procedures Testing of hip extension and external rotation range
McConnell, 1998: McConnell, 1996). The distance
of motion in prone lying revealed tightness of the
from the middle of the patella to the medial femoral
anterior hip structures. The patient was examined in
epicondyle was greater than the distance from the
a figure of four position, with the underneath foot at
middle of the patella to the lateral femoral epicondyle,
the level of the tibial tubercle. The distance of the left
indicating a laterally displaced patella. The posterior
anterior superior iliac spine to the plinth was 10 em,
edge of the lateral border of the patella was difficult to
whereas the right was only 6 cm from the plinth.
palpate, with the medial border sitting further from
Additionally, the stiffness of the subtalar jOint was
the femur, thus indicating a laterally tilted patella.
confirmed in this position. The lumbar spine was not
There was also a posterior displacement of the inferior
palpated at this time because there was nothing in the
pole of the patella.
history to indicate lumbar involvement.
� I J -
D
REASONIN G DIS C U SSION AN D CLI NICA L REASON I N G COMME N TARY
How did the initial observation of the patient fit
usuaUy associated with a tight ITB and poor function
in with your working hypotheses?
ing of the posterior fibres of the gluteus medius muscle. Tightness in the ITB results in overactivity in the TFL and diminished activity in vastus medialis
• C l inician's answer
obliquus (VMO) and the gluteus medius posterior
Patellofemoral dysfunction may arise from abnormal
fibres. The faulty alignment pattern remains because
gait patterns, primarily caused by poor dynamic lower
the muscles in a shortened position (usually two joint
limb mechanics. Internal rotation of the femur is
muscles) are readily recruited and are strong, whereas
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13 PAT E L L O F E M O RA L PA IN IN A P RO F E S S I O N A L TENNIS PLAY E R
muscles in a n elongated position (usually postural
the lack of knee flexion at heel stru<e, causing the
muscles)
patella to further irritate the inl1amed fat pad
are
dimcult
to
recruit
and
are
weak
tight ITB, which the patient rests on when
(Sahrmann, 2(02). A patient with a shortened ITB often demonstrates excessive medial rotation of
the
standing on one leg with
CJ
fully extended knee.
hip during the stance phase of gait, which means that
further irritating the fat pad
the pelvis on the opposite side drops,
tightness of the anterior hip structures, which
giving
a
external rotation,
Trendelenburg-like appearance (Sahrmann, 2002).
decreases hip extension and
Tills hip movement will increase the dynamic quadri
thereby decreaSing gluteus medius posterior
ceps
(Q)
angle (D'Amico and Rubin, 1986) and hence
fibre control and increasing TFL tightness
increase the potential for patellofemoral pain.
increased stiffness of the subtalar joint, thus
Initial shock absorption should occur with knee
transferring the shock absorption further up
l1exion of 10-15 degrees, because the loot is supinated
the kinetic chain to the pelvis: if the subtalar
when the heel first strikes the ground. This knee
jOint does nottake some of the load. the load is
flexion, which is accompanied by internal femoral rota
then transferred from the foot through the
tion, should immediately be followed by rapid prona
knee, which also does not absorb the stress. up
tion of the foot. Reduced knee l1exion on heel stril<e
to the pelvis, causing a 'jarring' at the knee
means that the ground reaction force is not minimized
that loads the inl1amed fat pad
at the knee, so greater load vvill need to be tal<en
lack of pelvic control. increasing the internal
through the foot (Powers et al., 1997). If the foot is also
rotation of the
stiff, as in this case, then the shock absorption must
the dynamic
occur at the pelvis, with increased anteroposterior tilt
lower extremity and increasing Q angle.
• ITB friction syndrome causing the lateral pain:
or rotation movement or lateral l1exion movement. The
supportive findings included: tight ITS, so it 'rubs' on the femoral epicondyle
normal pelvic range of motion during gait is 4 degrees of lateralilexion, 7 degrees of anteroposterior tilt. and
laterally tilted and displaced patella, which
10 degrees of rotation (Perry, 1992). Reduced knee
indicates tightness of the ITB because most of
rJexion on heel strike may also result in poor inner
the lateral retinaculum arises from the ITB
range eccentric control of the quadriceps muscle.
new rigid orthotics. which further minimized
As this patient presented with internally rotated
the shock absorption through the foot. provid
femurs, tibial varum, a high-arched foot and 'locked
ing to the knee an externally rotating distal
back knees', then his shock absorption was diminished
force on an internally rotating proximal force
at the subtalar joint and the knee: consequently, he
increased stiffness of the subtalar joint
had to absorb more shock at the pelvis. This caused an
poor pelvic control.
increase in the lateral tilt and rotation of the pelvis as his hip external rotator and abductor muscles were inadequate for controlling his pelviS. The locking back of his knee
D
further aggravated his fat pad problem.
These last three findings are important because load is transferred through the lower extremity to the pelvis if shock absorption is reduced through the foot; as a result, there will be increased dynamic pelvic movement. The lower leg needs to rotate internally on
Could you please describe your principal
heel strike: however,
diagnostic hypotheses at the end of the
examination ( with supporting and negating
a
rigid rearfoot and an unforgiv
ing high corrective orthotic will create an external
evidence). including any significant biomechanical
rotatory moment, so the ITB attempts to absorb the
or other factors contributing to the problem?
force [rom these two opposing moments. If the pelvis exhibits an increase in lateral tilt, then the TFL tight
• Clin ician 's answer
ens, decreasing its l1exibility. This can affect the distal course of the structure, that is the distal end of the
The principal diagnostic hypotheses were:
ITB, predisposing the patient to ITB
• fat· pad irritation causing the inferior pain: sup portive l1ndings included: the
enlarged fat pad
- the posterior tilt of the inferior pole
II
syndrome .
Bearing in mind your response to the previous question. what then were your specific goals for treatment. both short and long term?
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I I
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
• Clinician's answer
• Clinical reasoning commentary
The specifi c short-term goals were to:
The p r ocess of
• minimize t h e fat pad irritation by unloading the painful structures
hypothesis.
in
generat i n g and prioritizing whatever
category
it may
a
fit.
requires the ability to recognize salient clinical
• improve the mobi l ity of the anterior h ip structures
fi nd i n g s retain those t1ndings in short-term mem
to increase hip extension and external rotation;
ory. and synthesize the patient data to de termine
this will decrease ITB tightness
the dom inan t hypothesis. As discussed in Chapter 1. a number of clinical fe a tu re s will provide sup porting and negating evidence. and it is rare that a single feat u re will completely con I1rm or com pletely negate a pa rti cul a r hypothesis. In this
• improve gluteal and eccentric i nner range quadri ceps muscle control. The specific long-term goals were to: • improve the endurance capacity of the VMO and the gluteus medius muscles
,
response. the clinician has highlighted how all the patient information must be weighed. with
• incre ase the subtalar joint mobili ty
the s tre n gth of the supporting data ve r sus the
• return the patient to competitive tennis • teach the patient how to recognize symptoms and prov ide him wi th slTategies to self-manage his con
strength of the negating data determining the dominant hypothesis
.
dition to prevent recurrences.
[3'-"·II'I'43··'§U_ • First treatment Initial treatment involved loosening of the tight deep lateral retinacul a structures by soft tissue massage, while the patella was being medially tilted. The patient was
given a st retching exercise in prone ly ing
for the tight ante ri or structures (adductors. TFL. psoas, ante rio r capsule. iliofemoral ligamen t) which he was .
instructed to do twice a day for five repetit ions
.
Fig. 13.2
Gluteus medius posterior training. The
patient stands side-on to a wall. with the leg closest to the wall flexed at the knee so the foot is off the ground (the hip is in line with the standing hip).AII of the patient's weight should be back through the heel of
Fig.13.1
Unloading the fat pad.With the patient sitting
on the edge of the chair. the unload tape is started at the tibial tubercle and lifted out to the joint line. The soft tissue is lifted up to the patella. (From McConnell.
2002.)
the standing leg. which is slightly flexed. The patient externally rotates the standing leg without turning the foot. the pelvis or the shoulders. (From McConnell,
2002.)
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13 PATELLOFEMORAL PAIN IN A PRO FESSIONAL TENNIS PLAYER
With the patient in supine lying tape was ap plied to ,
the patella The flfSt piece commenced at the superior .
and resting against the wa ll. The patient was instruc ted to rotate the standing leg externally
without
margin in the middle of the patella to tilt the inferior
moving the hip or the foot and to hold the position for
pole and the lateral border of the patella anteriorly.
15 seconds (Fig. 1 3 2). .
The second piece was also anchored superiorly at the
Once this exercise was suffiCiently familiar to the
lateral border of the patella in order to correct the
patient that be could re peat it regularly at home, dual
gli de. This was followed by a 'V' tap i ng from the tibial
channel biofeedback traini.ng was commenced with
tubercle to the medial and latera l jOint lines to unload
the electrodes on the VMO and vastus lateralis
the fat p ad (Fig. 13.1), as well as another strip of tape
(VL) musc les . Em phasis was on the timing and inten
[rom the lateral femora l condyle diagonall y across the
sity of
[1'8 to decrease the tension on the band. After the tape
patient performed small-range squats, the VMO activ
was appl ied the patient was retested on the stairs and
ation was delayed and the VL contraction was g reater
cUd not experience any symptoms.
in mag nitude ensuring the knees were not locking
the VMO contraction. Initially
when the
,
Training the posterior fibres of the gluteus medius
back (being forced i n to end range extension). The
muscle in weight bearing was also an immediate pri
patient was also shown how to tape his knee while sit
-
ority for treatment, both to decrease TFL tightness
ting on the edge of a chair with the leg extended but
a nd to improve pelvic stabilit y. The patient stood on
rela xed. In addition he was shown how to massage
the left leg aga i nst the wa ll . The hip of the right leg
and stretch the deep later al retinacula structures in
was in line with the left hip, but the knee was flexed
sitting.
,
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
D
What clinical findings led you to suspect that the
activated 5.6 milliseconds earlier than the VL. Even
VMO required retraining? In addition to your
though this fmding was statistically significant, the
own clinical experience, what evidence supports
authors questioned the functional relevance. The above results are at odds, however,
this approach?
with
the find
ings of other investigators (Gilleard et aJ., 1998: Karst and Willett, 1995; Powers et aI., 1997), who reported
• Clinician's answer
that the VMO dld not rlfe earlier than the VL in asy mp
The left VMO activity was measured relative to the VL
tomatic volunteers and that the VMO activation was
ac tivity, and this was compclfed \"'1th the ratio on the
not delaye d in symptomatic individuals. It is of interest
asymptomatic side. The VMO muscle was not activat
to note, therefore, that Cowan et a1. (20 0 1 ) found that,
ing early enough d uring small knee bends and was
even though the majority of patellofemoral sufferers
exhibiting less act ivi ty than the VL. However, the signal
had a de l ayed onset of VMO relative to VL on a stair
was not normalized. The issue of VMO and VL timi ng is
stepping task (67% concentrically, 79% eccentrically )
still controversial. Voight and Weider (1991) found
there were still some whose VMO activation preceded
,
that the rel1ex response time of the VMO was earlier
their VL activation. Additionally, these investigators
than that of the VL in
asy mpto m at ic group, but in
found that some of the control subjects (no history of
a symptomatic pate ll o fe m oral group there was a rever
patellofemoraJ pain) exhibited a delayed onset of VMO
an
sal of the pattern. These fi n din gs were conflfmed by
relative to VL (46% co ncentrically 52% eccentric a lly )
Witvrouw et al. (1996), but curio us ly these investiga
on the stair-stepping task. This study by Cowan et al.
,
tors found that there was a shorter reflex response time
may clarify some of the discrepancies evident in the lit
in a symptomatic patellofemoral group relative to a
erature
control group. Further suppo r t is pro vided by the work
researchers have found a delayed onset of VMO relative
of Koh et aJ. (1991), who examined isokinetic knee 1 extension at 250 degrees/s- (following hamstring
groups only occurs when there are sufficient subject
muscle
numbers to tease out the dlfferences. The fmdlngs of
preactivation) and
found
that the
VMO
with
regard
to
timing,
i.n
which
some
to VL but others have not. The stratification of the
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C L I N I C A L REASO N I N G I N ACT I O N : CASE STU D I ES F RO M E X P E RT M A N UAL T H E RAPISTS
some of the earlier studies may not have reached statis
of treatment per week for 6 weeks . The treatmen t group
tical significance because there were too few subj ects
received patellar taping. fi gure of four stretc h es. ham
.
Although the early li tera ture s uggests there is a d if
string stretches gl u teal training and specific VMO train
ference in the ratio of the
V MO a n d VL activity. with t h e V1 ac tivity bein g greater than that o f the VNIO
ing vvith a dual channel biofeedback device. The p lacebo
(Mari a n i and Caruso. 1 9 7 9 ) , more recent literature
degrees of knee Ilexion in the line of t he femur. detu ned
has not s upp o r ted
this contenti o n . Th is may be
becau se the earlier s tu d ies did n ot tromy ograp h i c
,
group received placebo taping, which was applied at 90 ultrasound and massage around the patella
with medi
normalize the elec
cated gel . The symptoms in bot h groups decrea sed . but
(EMG) data. Normalization i nvolves
the treatment group h a d a far gre a te r improvement
obtai n i ng a ratio of the recorded mus c le activ i ty a nd
(vi sual a n alogue scale, p
muscle activi ty from the maximal vol u n tary contrac
ment scale. p
=
=
0 . 00 1 : fu nctional assess
0 . 0 0 0 1 ) . Another interesting fi nding
than the VL in the
tion (MVC ) , which then permits the comparison of the
was t hat the VMO was lking earlier
ratio o f one muscle relative to its MVC wit h another
treatment group (both concen trica lly and eccen t ri cal ly)
muscle rela tive to i ts MVC. For example. if the reco rded
after 6 weeks, whereas the timing of the VMO in the
VMO a c ti v i ty is 50 fL V and the M VC is 2 0 0 fL V and the
pl acebo group was u n changed after th is time (i .e. it
measured VL activity is
remained delayed compared wit h the VL) .
100 fLV and the MVC is
400 fL V. then the ratio VMO : V1 is 1 : 1 . There has been so me d iscu ssion that normalization i s a ffected by the presence o f pain , wh ich will mask d i ffere n ces because there could be error i n the MVC and this may appear in
• C l i n ical
reason i ng com m entary
The use of both research- and experience- based evi a n swer. Expert clin icians. this clinician. routinely consider the t wo
the error o f t he recorded EMG ( Ya n g and Wi nter,
dence is apparent in t h is
1 9 8 3 ) . There h a s also been some deb ate about the rel i
such as
abi l i ty of t h e m aximal con traction . castin g doubt o n
types of
the no r m a l iz a ti on
though the evidence may not always be in complete
process. Howard a n d Enoka ( 1 9 9 1 )
in their decision making. even
e videnc e
fo u n d that there was considerab le vari ation i n t h e
harmony. However. it is a n error of clinical reason ing
MVC of the VL EMG , e v e n t h o u g h t h e force exerted
to take <my single research fmding in isol a t i o n
by the
leg remained constant
.
I n terestingly. Yang
.
as
it is
finding. When research fi n d ings
lor a single clinical
wit h skilled rellectivc c l i n ical experience.
a nd W i n te r ( 1 9 8 3 ) fo u n d t h a t the averaged recti
are
fied EMG had a coe ffi c ie n t of variation ( s ta n da rd
the practice strategies in question shou ld nol simply
at odds
de v i a t i o n/ me a n ) of 9 . 1 % within 1 day a n d of 1 6 . 4 'Yo
be discarded . Rather. further critical rellection on the
be twee n days.
c l inical use of those s trategies must be un dertaken.
A
rece n t
randomized.
controlled trial of
double-bli n d .
placebo
a lo n g with further
research, possi bly with grea ter
intervention programme. similar
attention to various su bgroups . which may respond
to that received by the ten n i s pl ayer. showed that the
differently. Here. the c1 i n ician's c ritic a l awareness of
an
treatment group d emonstrated Significantly
greater
improvements i n pain and functi onal activities than the placebo group (Crossley et a1 . , 2 0 0 2 ) . There patients in each g roup
were 3 6
an d all patients received 1 hour
E1l",gi-'itghi·&i·fB§;·'§"_ The patient returned after a week
and was cons i derab ly
improved: he was not experiencing any p ain on sta irs and was a n xious to start playing tenn is a ga i n . His activ i ty relative to hi s VL activity improved . but it
VMO
had somewh at
w as stilJ del ayed in onset a nd w a s of
l e sser magnitude as measure d on the biofeedba ck
the quality of the research evid e nc e and her willing ness to reta i n
an
open mind on this whole issu e
(which is as yet still clearly u nresolved ) is
a
hallmark
of cli nical expertise.
machine . A n inhibitory VL taping was
firmly app lied to
the thi g h to en hance VMO activ i ty (Fig. 1 3 . 3 ) . This imme dia te l y
decreased the VL activity. resu l t i ng i n
VM O becomin g more active. After 2 0 rep e tition s o f the small squats , the patien t began t o feel fatigu e
in the
VMO region . At subseq uen t visits. fur ther fm e tu n i ng of
the
quadri ceps con traction occurred . with the patient
Copyrighted Material
13 PAT E L L O F EM O RA L PA I N I N A PRO F E S S I O N A L TENNI S PLAYER
the calcaneu m being moved l a te r a lly. This position was a dopted to sim u l a te the mo m e n t immed i a tely after heel s trike when the s u b t a lar joint should be pronat ing. A fter s i x v i s i ts ( o v e r a period of 2 m ont h s ) the VMO was ac t i v a t i n g earlier than the VL a n d was se v e ral t i mes g rea t e r in magn itu d e . The gl u tea l exercise had been progressed to 30 s e c o n d s . with the patient prac tising in front o f a mirror st a nd i n g o n the left l eg a nd r a pid ly moving the righ t leg back and for t h . while keeping a s t ab le pelvis. He wa s a l so m a i n t a i n i n g a s t ea d y p e l v i s w h i l e l ow e rin g his r i g h t leg d own off a s m a l l s te p a n d re t u r ni n g b ack up to t h e s tep. He re p e at ed this exercise slowly 20 t i me s wi t hout paus ing i n order to i n crea s e the e n d u r a n c e of t h e VMO a n d g l u t e a l mu s c u l a tu re . A fter 3
Fig. 13.3
m o n th s t h e p a tient w a s b a c k p la yi n g tour
n a m e n t ten n i s . His k n ee was still t a p e d for pl ay in g , I n h i b iting the vastus latera l i s . Th i s i nvolves
apply i ng three p i eces of fi rm ta pe from m i d-thigh a n t e r i orly, passing laterally to m i d -t h i g h posterio rly. The soft tissue is fi r m l y c o m p ressed over the vastu s lateral is a n d t h e i l i o ti b i a l b a n d . ( F ro m M c C o n n e l l , 2002.)
pra c ti s in g s i de way s movements . and simu lated fore h a nd . backhand a n d se rv i c e manoeuvres. The s u btalar j o i n t was mobi l ized in side l y i n g . wit h the foot in ne u tral ( plan targ rade). the tibia and tal u s st a bil i z e d , an d
but n o t for daily a ct ivit i es . A t t h is stage, the ac t i v i ty
of VMO r e l a t i ve to the V L was fo u r t i m e s grea ter. a s measu red on a d ua l c h a n n e l biofeedback dev ice. The p a t i e n t was n o t experie n c i n g a ny pain o n repeated one- leg sq u att i n g a c t i v i t ies b u t was fe arfu l about p a i n ret u r n i n g w h e n he wen t b a c k to tennis. The patien t p e r s p i r e d g re a tly when p l ay i n g so the tape h a d to be re a p p l ied d u r i n g h i s m atches . It took a fu r t h e r 3 m o n t h s before the p atie n t felt s u ffi ciently c o n fi d e n t t o pl a y w i tho u t tapi n g . the
R E ASONI N G DIS C U SSION A N D C L I N I C A L REASO NING C O M M ENTA RY
D
T h e re appears to be some psychosocial issues with this athlete's presentation. Could you e l abo rate on any of th ese you considered to be clinically significant? What strategies
(if any)
d id
you employ to manage this aspect of the problem?
• C l i n i c i a n 's an swer The pla ye r was very c o nc e r ned a n d anxious a bo u t h i s r an kin g and h i s fitness , whic h he fe l t was det eri or a t i n g by th e second . It was i m p e r a t ive th a t I worked in closely with the p l a y e r' s fi tness coach. w h o was w r i t ing programmes to mai n t a i n c a rd iova s c u l a r fi tness a n d upp e r b o dy s t r en g t h d u r i n g h is r e h a b i l i t a t io n . Together, we devised a re h a b i l i ta ti o n p l a n for the
p laye r i n which he could see the s h o r t - t er m a n d l o n g term goal s and how we were goin g to m e a s u r e them (principally m e a s u r i n g pai n and EMG a c t ivity ) . In i t i a l l y th e pl a ye r was d oi ng q u i te a b i t of water running, w h i c h n o t o n l y i n creased h i s he a r t rate but also h elped to m a in ta i n his runn i n g fo r m . Other car diovascu l a r wo rk i nc l u d e d c yc l i n g on a st a tio n a ry b i ke (which became p a r t of h is prog ramme) as soon as he had no pain d o i n g that activity. The co a c h a nd I al s o exa m ined some of the p l a ye r ' s techniques from old v ideo foo tage. We were par t ic ular ly interested in the o pen stance fore hand and discu ssed strategies w i th the p l a y e r to m i n i miz e p i v o t in g ex c es s iv ely a ro u nd the knee a nd use m o re t run k r o t a t i o n . Th e s e tec hn i q ue a dj u s tm en ts were worked on d u r i n g the re h a b i l i t at io n of tbe kn ee .
Copyrighted Material
C L INIC A L R E AS O N ING IN ACTIO N: C A S E STU D I ES F RO M E X P E RT M A NUAL TH E R A P ISTS
At t h e end of the second month , t h e player com
profession a l s . In this
menced i n te r v a l tra i n i n g : short sprints fo l l owed by
case.
the i mportance that
t h e expert clin ician p l a c e s o n a h o l i st i c and team
l o n ger s l ower r u n s . Slow ly, plyometric tra i n i n g was
approach to the patien t's problem is wel l illustrated .
i n t r od uced into the train i n g progra mme a s t h e core
Consideration is gi ven to the patient's p sych os o c ial
stab i l i ty improved . p a r tic ula rly g l u te a l work.
issues . maintaini n g h i s general Iltness and upper body m u s c le stren g t h . and involvement of the
• C l ini c al
coaching staff. such as in addressin g his
reasoning com m e n tary
t e c h n ique The p atien t is .
Manual the rap i st s are often c ri t i c i se d for relying on
a l so
playing in
very m u c h involved
a
his reh abi l i tation progranune a n d has been empow
tissue-focussed and reduct ionist approach to chro n ic
ered with the mea ns a n d re sp o n si bi l i ty to make a
muscu loskeletal prob lem s
and for inadvertently
significcmt contribution to his own recovery. Suc h a
encouraging patien t passivity a nd dependence on
comprehensive approach to rec a lcitra n t c l i n ical
the t herapist. They are
a l so
problems is crit ical to a s u cce s s fu l outcome and only
often g u i l ty of wo r k i n g
in isolation and fa i l ing to seek appropriate input
serves to enhance the
i n the managemen t p ro c e s s from othe r relevant
in the eyes of their colleagues and patients.
Outcome
stand ing of m a n u a l th erapis t s
exercises consis ting of the s ta ndi ng glu teal exerci s e
,
small-r a n ge squats. and the figure of four stretc h in When the t o u r came back to Austra l i a . the patient
prone lyi ng. His VMO activi ty was still fou r ti mes t h a t of
returned for review. He was stil l doing his maintenance
the VL a n d he h ad been sym ptom free for 12 month s . -
• References B r u k ner.
P a nd K ha n . K. ( 1 9 9 3 ) . CUn i c a l
S ports Med i c i n e . New Yor k : McGraw-Hi l I .
( 1 9 9 8) . The effect of p a te l lar t a p i n g on the o n set of vastus med i a l is o b l i q u u s
Cowa n . S . M . . Be nn e U . et
G i Ueard . W. . McCo n n e l l . J . and Pa rsons. D.
K . L . . Hodges. r. w.
a l . ( 2 0 0 1 ) . Del ayed onset o r of v a s t u s
e lectro myog r a p h i c activ ity
persons w i t h p a te l l o lemora l pa i n .
s u b l u x a t i o n of t h e p atel l a . Jo u r n a l o f
P hysica l Therapy. 7 8 . 2 5 -3 2 .
p a in syndrome. A r c h i ves of P hys i c a l
CO: Aspen P u b l i shers .
K . M Benn e l l . K . L . G reen. S . et 3 1 . ( 2 0 0 2 ) . P hysica l therapy for
Crossley.
G re l s a m e r.
Hoppen fe l d .
S. ( 1 9 7 6 ) . Phys ical
Ex a m i n a tion of the S p i n e a n d
1 8 3- 1 8 9 . . .
.
patellofemora) p a in : a rand o m ized. d o u b l e -b l i n d . pla cebo-contro l led tr i a l .
Extre m i ties. N e w Yo rk: Appleton-Ce n t u ry-Crofts . Howa rd . J. a n d Eno k a .
R. ( 1 9 9 1 ) .
M a x i m u m b i l a tera l con tractions are
A merican Journa l o f Sports Medic i n e .
mo d i l1ed by n eura l l y med i a ted
3 0 . 8 5 7-8 6 5 .
i n te r l i m b effects. Jo u r n a l of App l i ed
D · Am ico. I . C . a n d
Rubin . M . ( 1 9 8 6) .
T h e i n flue nce of foot orthoses on the
P hysiol ogy, 70. 3 0 6-3 1 6 . Karst. G .
a n d Wil lett. G . ( 1 9 9 5 ) . Onset activity in
quad riceps a ngie. Journal o f the
t i m in g o f elec tromyographic
A merican Podiatry Assoc i a t i o n . 7 6 .
the vastus med i a l i s obl i q u e a n d vastus
3 3 7-3 3 9 . Dye.
S . . Vaup e l . G . . Dye. C . e t 3 1 . ( 1 9 9 8 ) .
Conscious n e u rosensory m a p p i n g
P. a n d Caruso. I . ( 1 9 7 9 ) . A n of
electromyog ra p h i c i n vestigation
l a tera l i s i n s u bj e c ts w i th patel l o re m o r a l Medi c in e a n d Re h a b ili t a tio n . 8 2 .
Maria n i .
a n d v a s t u s l a tera l i s m u s c l e acti v i ty i n
R . a n d McCon n e l l . J . ( 1 9 9 8 ) . T h e Pate l l a . f\ Tea m Appro a c h . Aspen .
med i a l is obliq u u s relative to v a s t u s
pa tel l a . l o u r n a l of Biomec h a n i c s . 2 5 .
6 3 7-64 3 .
l a tera l i s muscles i n subjects w i t h and w i t hout p a t e l l o femoral p a in syndro m e .
7 5 . 8 13 -8 2 2 . Kend a l l . F. a n d McCre ary. L . ( 1 9 8 3 ) .
B o n e a nd l o i n t S u rgery.
6 1 . 1 69-1 7 1 .
McCo n n e l l . j . ( 1 9 9 6 ) . Piltellofernora l pa i n a nd so [,t tissue i nj u ries. [ n A thletic Inj u ries a n d Reh a b i l i tation U·E. Zach azews k i .
D·I· Magee and W.S.
Q u i l le n . eds.) pp. 6 9 3- 7 2 8 . Lond o n : S a u nd e r s . McConnel l . j . ( 2 0 0 2 ) . The physical therapist's approac h to pate l l o remoral d isorders. C l i n ics i n Sports Med i c i ne.
2 1. 3 6 3- 3 8 7 . McKenzie.
A . M . a nd Taylor. N.E ( 1 9 9 7 ) .
C a n p hysi o t h erapi sts locate l u m bar s p i n a l levels by palpation? Phys i o t h e r a py.
8 3 . 2 3 5-2 3 9 .
Per r y. J . ( 1 9 9 2 ) . G a i t A o a lys i s . New Yo rk: Slack Corpora tion . Po t ter.
N. a n d Ro t h s te i n . 1. ( 1 9 8 5 ) .
P hys i c a l Thera py.
[ o tertester rel i a b i l i ty o f selected
h u ma n k n e e w i t h o u t i n tra
Muscle Tes L i n g and Fu n c t io n . Londo n :
Physi c a l T h era py.
a rti c u l a r a n aesthes i a . A m e r ic a n
Wi l l i a m s & W i l k i n s .
o f t h e i n ter n a l structu res o f t b e
Journ a l o r Sports Med i c i n e . 2 6 .
7 7 3- 7 7 7 .
1<0 11 . T.. Grabi ner. M . a nd DeSwa r t . R . ( 1 9 9 1 ) . [ n v i vo tra c k i n g o f t h e huma n
Copyrighted Material
c l i n i c a l tests o f the sacro i l i a c j o i n t . Powers. C . . La n d e l .
65. 1 6 7 1 -1 6 7 5 . R . Sos n i c k . T. et a l . .
( 1 9 9 7 ) . T h e effects o f patel l a r tapi ng on stride c h a racteri s t i c s a n d j o i n t
1 3 PATELLO FEMORAL PAI N IN A PROFESSI ON A L T E N N I S P L AY ER
m o t i o n in s u bjects with pat e l l ofemora l
O rt h o p e d ic a n d Sports P hysical Therapy. 26. 2 8 6-2 9 l . p a i n . J o u r n a l of
S po r ts Medi c in e , 1 0 . 1 3 1-1 3 7. Wa tso n , C Propps. M . G a l t . W. et a l . Journ a l of
. .
.
vastus l ate ra l i s in n o r m a l su bjects a n d su bj ects w i t h pate l l o femora l p a i n
synd rome. J o u r n a l o f Orthopedic
( 1 9 9 9 ) . Re l iabi l i ty of measu rements
and S po r ts
Tre a t m e n t of Moveme n t Impairment
obta i ned u s in g McConnel l ' s
1 6 0-1 6 6 .
Systems. Lo n d o n : Mosby.
c l assification of pa tel la r orientation i n
M. a n d We i d e r D. ( 1 9 9 1 ) . Compa rative re ll ex response times o f t h e v a s t u s m ed i a l is a n d t h e
sy m ptoma tic a n d asymptomatic
S a h rman n . S . ( 2 0 0 2 ) . D i a g n osis a n d
Vo i g h t.
.
VHs t u s l a te r a l i s i n norm a l s u bj e cts
Ya n g .
J.
P hY S i c a l Thera py. 2 4 .
a n d Win ter. D . ( 1 9 8 3 ) .
Electromyography r e l i ab i l i ty i n
s u bj ects. J o u r n a l of O r t h o pe d i c and
ma x i m a l con tr a c t i on s a n d
S p or ts P hy s ic a l Therapy. 2 9 . 3 7 8 - 3 8 5 .
s u b m a x i m a l iso metric
Witvro u w. E . . S n eye rs . C . . Lys e n s , R . e t a l .
c o n trac tio ns . A rc h i ves of PhYS i c a l
a n d s u bjects w i t h extensor
( 1 9 9 6 ) . Comparative reflex respo nse
Med i c i n e a n d R e h a b il i t a t i o n . 6 4 .
m e c h a n ism dysfu nc t i o n . A merica n
times of v a s t u s media l i s ob l i q u u s a n d
4 1 7-4 2 0 .
Copyrighted Material
CHAPTER
14
Self-management guided by directional preference and centralization in a patient with low back and leg pain Robin McKenzie and Helen Clare
�
S UBJE C T IVE E XAM IN AT I O N
Jamie is
a
3 2 year-old carpenter who -
for the past
2 years has been self-employed building houses, requir
ing only occasional assistance. He complained of back and right leg pain radiating below the knee (Fig.
14.1)
and had experienced a similar problem on lwo previous
occasions, the most recent being 2 years ago. Jcunie was advised 3 year s ago that he had
a
degenerated disc at
L4-LS. He refused surgery and went to
a
chiropractor
wilh a successful outcome. The symptoms had been present for 5 weeks and
had
commenced on the right side of his back. The leg
pain had appeared more recently. The patient believed the leg pain was getting worse with the passage of time.
right com pl ained
Jamie stated that the pain in the cenlre and side of his lower back was constant. He
that the pain radiated into the right buttock and thigh on performing certain movements, but these pains ceased 'when he returned to
a
more upright position.
His pain was worse w ith prolonged bending and sit ting. When driving his truck, the pain extended into the lower leg and hi s foot tingled and at times becomes 'dead'. His back and leg pain also incr ea sed if he stood erect for prolonged periods. He had particular diffi
culty
getting out of bed in the morning because of
increased back an d buttock p a i n . Coug hing and sneez ing
prod uced or increased p ai n in the rig ht buttoc k . partially
The patient noted the back pain was
re l ie ved, and the buttock and leg pain abolished, when he lay face dov.TJ1. His leg pain decreased when he walked short distances but inc re ased if w alki ng was pr ol onge d .
He
could then obtain relief temporarily
Fig. 14.1
if
206
Copyrighted Material
Area of patient's pa in.
14 S E LF- M A N AG E M E N T I N A PATI E N T WI TH LOW BACK A N D LEG PAIN
he bent slightly forward. All symptoms were also
He was now taking two Digesic (dextropropoxyphen e
relieved if he lay in bed face up with his knees bent.
30mg + paracetamol325mg) table ts three times per
However. the symptoms never completely ceased in
day for pain relief. Radiographs showed slight narrow
the back or upper thigh.
ing at L4-L5.
The patient's general health was good. there was no weight loss. and until recently he refused mectication.
REASONING DISCUSSION AND CLINICAL REASONING COMMENTA RY At this stage what were your initial thoughts!
usually be felt constantly as long as the concentra
Which hypotheses (if any) were you considering
tion of chemicals is sufficient to activate pain recep
with respect to the source of the patient's
tors. Pain can also be experienced constantly when
symptoms!
mechanically dislocated tissue (such as discal tissue) is
displaced and deforms adjacent normal soft tissues .
• Clinicians' answer
The concentration of chemicals in an inflammatory
It was noted that the patient's age placed him in an age group with a high incidence of low back pain and that in his job he must flex and lift frequently. The patient's description of increasing peripheralization (McKenzie . 1981) of pain and paraesthesia typically occurs in the presence of intervertebral disc pathology or prolapse. The peripheralizing of back and leg symptoms over time also suggested the problem was progressive and his condition was worsening. As this disorder has marked consequences if neglected. it would be unwise to ignore the signU1cance of progressively increasing radiating symptoms in the search for more obscure causes for his p robl em
.
It was likely that the back and leg symptoms were
related. but back and leg pain are not always con nected. Supportive evidence was needed. which could be obtained by increasing and decreasing the lumbar lordosis (flexing and extending the lumbar spine in sitting) to test the effect of spinal loading on the leg symptoms .
D
condition does not generally reduce with change of position or unloading or exercise. Therefore. if the symptoms are intermittent or influenced by position. they are unlikely to be inflammatory in origin. Similarly. repeated moveme nt or prolon ged loading will either have no effect or will increase rather than decrease the symptoms. However, if the symptoms result from internal derangement of a lumbar disc. repeated movements in one direction may increase displacement and cause an increase in pain. while movement in the opposite direction may decrease dis placement and cause a decrease in pain. In this case. the pain was constant and so it could have been chemical in origin or have arisen from con stant m echan ical deformation. such as might occur
with
an
internal disc derangement. The behaviour.
however, suggested the pain was not primarily chemical in nature. It is improbable that pain related to inllam mation would appear and ctisappear on change of pos ition. The behaviour did tend to support the hypothesis that the symptoms were likely to have arisen from increaSing and decreasing mechanical disc deform
At the conclusion of the history, did the behaviour of the symptoms with movement tend to support or discount your hypothesis! Were there any factors (e.g. environmental, psychosocial, biomechanical) that you considered had contributed to the onset or deterioration of his disorder!
ation. The constant back pain was, therefore. most probably caused by an' internal disc derangement. which could increase or decrease. thus provoking in termittent pain in the leg according to the patient's position or movement. The reduction in leg pain on waU<ing a short dis tance may have been a consequence of the lumbar spine extension effect of walking. However. walking
• Clinicians' answer
longer distances may have caused prolonged com
Pain can arise from either chemical or mechanical
pression loading of
causes (Wyke. 1980). Pain of chemical origin will
peripheralization.
Copyrighted Material
a
posterior disc bulge . leadin g to
Perhaps the relief
n oted while
I:
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
bend ing (i.e. in slight spinal Ilexion) was a result of
work. Th is involved frequ ent aod sustained spinal
reduced compression of the posterior displacement.
flexion. Despite the risks. the patient was reluctant to
Unloaded flexion d ec ompresses the disc but is unlil e ly
ce ase work.
to reduce or alter the location of displaced tissue. The reported difficulty getting out of bed in the morning was also consistent with a mechanical disc problem . Compressive forces on a nocturnally imbibed
• Clinical reasoning commentary
disc would. under these circumstances. increase back
Pattern recognition is typical of the clinical
pain and the patient is at increased risk of aggravation of
soning process of expert clinicians.
symptoms in the first few hours of the day. Interestingly.
in this response. Early in the clinical session. cues
CIS
rea
is evidenced
it has been reported that recurrence of low back pain is
are reco gnized (e.g. area of the sy mptoms. age of
most W<ely in the first few hours of the day (McKenzie.
the patient) that relate to a familiar clinical pattern
1981;
or
Snook et al..
1998).
Differentiation between
syn dro me (e.g. peripheralization of pain possi
ation. If pain location changes or its intenSity reduces
disc prolapse). c l in ic al experience with simi lar cl ini c al presentations is integral to t h is process.
\vi th repeated movement testing. then the pain cannot
However. it is still necessary that the diagnostic
chemical and mechanical causes should be aided by the use of repeated movements during the physical examin
be chemical in nature. Sitting in
a
bly as a result of intervertebral
S i gnific ant previous
hypothesis be tested by further examination
truck elicited tingling a n d numbness in
(e.g.
increasing and de c re as in g the lumbar lordosis to
Jamie's right foot. Sitting in this position flattens or
determine the effect of lumbar posture on the
nexes the lumbar spine. The i ntermitte nt neurologic al
sympto ms) before it can be fully accep t e d and the
sy mptoms confIrmed intermitten t mechanical com
problem well understood.
pression or irritation of the spinal nerve root was
Hypo theses are not limited to ju st the structural
occurring, prob ably as a result of lumbar Oexion. The
source of a pat ie nt s c om pl a i n t
fact that the tingling and numbness was not constant
As illustrated in the clinicians' second answer.
'
(e.g.
lumbar
disc).
also suggested that the condition m ay have been
they
rapidly reversible. If root compression spontaneously
activity/participation restrictions (e . g
ceases, it is usually possible to identify the position that
lo n g dis t ances) pathobiological mechanisms (e.g.
causes the d ecompression. In this case, he described
chemical). factors contributing to the problem
central ization occurring in unloaded extension of the
(e.g. work environment). management and treat
may
also fall into other categories i ncluding .
w a l k ing
.
spine (e.g. lying prone). This suggested a good o u t
ment (e.g. 'extension principles of treatment'), and
come would likely be achievable with the use of exten
prognosis (e.g.
sion p rinC ip l es of treatment.
achievable'). These hypotheses together guide the
The only obvious factor that may have contribu ted
'
goo d outcome would likely be
ongoing examination by
a
re aso ning process in
to the problem. and which may have predisposed the
which they are eventually either refined or rejected
pa tient to rec urrence. was enviro nmental. that is his
on the basis of the cl i n i cal findings obtained.
tE
P H Y S I C AL EXAM I NAT I O N
On examination. Jamie sat slouched w i th a rounded
in the foot. Extension in standing increased h is back
back (i.e. in lumb a r flexi on). Correctio n of his s itting
and leg p ain and repetition worsened his symp toms
posture increased his leg pain. He stood with a flat
overall.
tened lumbar spine and leant to the left. Attempting
Loaded correction of the left lateral shift (Fig. 14.2)
to stand f ully erect was impossible and increased both
increased his right back pain b u t abolished the pain in
back and leg pain.
h is right lower leg and decreased the pain in the but
Flexion in standing did no t increase h is back p ain,
tock and thigh (i.e. it centralized the pain). Repeated
but a fter 10 repetitions he complained of increasing
loaded correction of the lateral shift reduced and
right l ower leg pain and slight ill-defined numbness
then abolished all symptoms below the bu ttock. The
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14 SELF-MANAG E M E N T IN A PATIEN T W I TH LOW BACK A N D LEG PA I N
Fig. 14.3
Exte n s i o n in lying with the pe lvis dis p l aced to
the left.
(Fig.
14.3). There was a steady reduction in the leg
pain as symp toms centralized. Simu l tane o usly with centralization, Ja m i e's ra n ge o f exte n s i on stead ily improved u n til it appeared a full and a lmost painless Fig 14.2
Loaded self-correction of a l e ft l ate ral s hift.
ra n ge was achieved . The patie n t was ins tructed to re tain a l u mbar lor dosis when he arose fro m the treatment table and to
symptoms ce n tra lized as a result o f latera l shift cor
maintain it when standing. On standi n g erect, Ja m i e
rectio n but did not remain better.
repor ted m i nor levels o f centra l and rig ht l ow back
A further series of corrections of the l a teral s h i ft
pain o n ly. He was asked to rem a i n very erect and walk
again resulted in a reduction of inten s i ty and central
abou t for a few minute s . After 10 minutes wa lking,
i zation of pain. Thi s , also, was of
te mporary nature.
he reported that his symptoms had remained centra l
Com plete reductio n of the disc derangement was not
ized and he was no t aware of a ny leg p a i n o r other
achievable i n the l o aded positio n , pro b a b ly beca use of
untoward sensations.
a
the difficulty of achieving an adequate extension
No further examination was conducte d . A neuro logical examin a tion was not performed as the symp
force in the stand i ng position. After placi n g the patient in prone lyin g and mov
toms in the leg were in termittent. There is no evidence
ing the pelvis away fro m the side of pain and fixin g
tha t muscle length or muscle control relates to i nter
him in this pos ition ( lumbar s p i n e right l a teral Oexi o n
vertebral disc pathology so tests for these were n o t
i n this case), t he p atie n t repeated extension in lying
performed.
� J_
REASONING DIS CUSSION AND CLINICAL REASONING COMMENTARY
Earlier in the examination, it was found that extension and repeated extension peripheralized and worsened the patient's symptoms overall. What, therefore, prompted you to add repeated extension to the shift correction? Did any other findings from the physical examination influence your decision making?
• Clinicians' answer McKenzie reported in 1979 a n d 1981 that extension performed in the presence of a lateral shift could �worsen symptoms o f disc prolapse and that correcting the shift is the first step in the red uction of a derange ment, prior to complete redu ctio n using extension .
Copyrighted Material
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
Altho u gh attempting to force extension in stanclin g in
D
Did you expect that the i m prove ment from the
the presence of a lateral s h i ft u sually results in an
extension exe rcise obtain ed in the unloaded
unacceptab le leve l of pain, this pro blem c a n be over
position would be maintained in loaded
come by plac ing the patie nt in the unloaded prone
post ures, particularly conSidering the patient's
lying positio n . Concep tu ally, this p roced u re applies
pain was worse in sitting and standing! If so, why!
a compressive force to the right posterolateral aspect of the inter vertebral disc. This, will in turn, theoret ically cause a posterolater al d isplacemen t of the disc n u cleu s to move to a more central l oca tion
.
Any
obstruction to extension should be red uced by this process and t h e p atient s range of extensi o n concomi '
tan tly improved. In this case, it w as found that the patient stood 01'1' centre with a left lateral s hift away from the side of pain ( i . e a contralateral shift) Lumbar spine extension was .
.
limited to 25% of anticipated normal range and lateral l1exion to the right was impossible past the midline. It was
lilcely
that righ t posterolateral disc fissur in g with
• Clinicians' answer Prov ided that the p atien t maintained lumbar spine exte nsion o n moving from the unloaded position to the load ed post ur e it was expected that any benefit ,
o bta i ned in prone lying would r e m a i n stab le on stand in g. This wo uld not have happe n ed if the patient had been permitted to flex. By maintaining extension, f u r ther posterior displacement of the dis c nucleus was prevented (Do nelson et al.. 1991). As the pain remai ned
ce ntra lized
fo l low ing
ambulation,
the
reduction of the displacement was likely to be stable.
nuclear displacement was respons ible for this pattern of movemen t limitation and forced the p atient to adop t
an
a n ta lgic pos ture. However, loaded extension was
• Clinical reasoning commentary the
causing peripheralization of p a i n and was, therefore,
Although
contraindicated until reassessment indicated other
ing within a c on ce pt u a l framework about a specific
wise. Although the sympto ms were centralized for only
structure (Le. tbe intervertebral disc), these answers
c l ini cia n s
have pr ese n ted their think
a short period with la teral shift correction, the respo nse
indicate that their clinical reason ing is not limited to
id entified the direction of movemen t that had the
just
potential to centralize and suggested that shift correc
patient's symptoms. Indeed, it is
tion was the ftrst motion to apply as part of the thera
framework has e n abled them to process the informa
a
consideration of the st ruc tu r al source of the app are n t
that this
peutic procedure. Therefore, unloaded s hift cor rection
tion from the movement examination
comb in ed with e xt en sio n was most lUcely to achieve
an d
reduction in these c irc umstances.
such as management (e.g. 'as part of the therapeutic
in many ways
explore hypotheses in several other categories ,
Other findings of note included the flexed posture
procedure'), contraindications to tre a tment (e.g.
(reversed lumba r sp ine lordoSi s). which p robab ly
l oaded flexion was now contraindicated'), and prog no sis (e.g 'reduction was likely to be stable'). Importantly, relevant p hys i cal impairments were
explained why prolong ed s itting i ncreased his b ack and leg pain a n d produced numbness in h i s foot. Periphe ralization was likely o cc u r r i n g as
'
.
. . .
r es u l t of
identified through a s y stema t ic assessment of pos
prolo nged l1exion, which incre ased sp i na l nerve root
tural (shift or list) correction, active movements and
a
compression. One flexion movemen t was not suffi
repeated
m ovemen ts in both s t a n ding and prone
cient to ca use root compression, b u t repeated l o aded
lyi ng (as
indicated
flexion also caused peri p heralization and progressive
relief fo u n d when lying face down). Similarly, atten
root compression. Therefore, loaded
fl exi on
was now
in
the
hi s t o ry by the reported
tio n to c on s i st e n c y in symptom responses
(e.g.
con traindicated u n til later assessme n t demon s trated
centralization versus periphcralization) p rovide d
o t h erwise.
evidence fo r a vi abl e treatment s tra teg y to be tested.
BW'lrfilfB'I,I§"_
cedure that centralized his sy mp toms (Le . extension
Jamie was advised not to remain at work. He agreed
i n lyi ng w ith his pelvis moved away from the side of
to this as he had no fina ncia l concerns and was
pain), 10 repe ti tions every 2 hours at home and to
impressed with his new-fo u nd ability to ma nage his
avoid to tally flexed postures or movements. He
own p a i n. Instru ction was given to carry ou t the pro
Copyrighted Material
was
14 SE LF-M A N AGEMENT I N A PAT I E N T W I T H LOW BACK A N D LEG PAI N
also instructed to maintain his lumbar lordosis when
explained to Jamie that when he had the abi lity to
sitting and was provided with and instructed in the
l1ex fully without pain. he could be reassured the
use of
a
lumbar roll for all si tting occasions.
present episode was over. However. as his occupa
The patient was advised to cont inue with the pre
tion
required
frequent
bendin g
and
lifting.
he
scr i b ed routine for several days unti l he had lit tle or
would need to perform extension movements regu
no pain. It would then be necessary to re-evaluate
larly during the course of the d ay to prevent any
him to ensure that his function was full. It was
recurrence.
REASONING DIS CUSSION AN D CLINICAL REASONING COMMENTARY
D
At this stage did you have in mind any other
reduction of stimul us . the p ain reduces in intensity
treatment options?
and becomes localized to the pOint of origin.
In t he present case, both subjective (pain drawing)
• Clinicians' answer
a nd objective (lumbar spine movement) improvement
No. because with such a clear-cut positive response to loading with the extension inlying exercise (i.e. the
centralization of symptoms. indicat ing a good prog nosis). it would be premature to consider other treat ment options at this point. Furthermore. the use of repeated movements plainly demon strated the opti mal direction in which to apply loading (directional preference) and the best procedure to achieve a reduction
needed to be demonstrated for progress to be deemed . satisfactory. This would indicate that the mechanical forces bei n g appl ied (extension in ly ing with the pelvis
displaced to th e left) were successfully red u cing poster ior clisplacement of the nucleus of the disc. a response known as the 'extension sign' (Kopp et al.. 1986). The extension sign is described by Kopp et al. as the ability to recover full extension ran ge.
in the mechanical deformation of pain
sensitive structures. This treatment is also consistent with the literature. which suggests that activity. espe cially self-applied activity. is beneficial for recovery from back pain (ACC and NHC. 1997: AHCPR. 1994: CSAG. 1994: DIHTA. 1999).
• Clinical
reasoning commentary
The recent shift toward evidence-based practice may. at first glance. appear to
be at odds with the
need for skilled clinical reasoning. However. the
t wo are not mutually exclusive. The expert clini cian recogn izes that evidence-based treatment
IEJ
guidelines are a convenient form of propositional
What specific outcome measure(s) did
knowledge that may help inform their clinical deci
you consider was most important in
sion making. for exam ple
the clinical guidelines Q uestion 1 supporting the use of self-appl ied activity. It should be considered . as the mature organism model suggests ( see Ch. 1) .
determining if progress was satisfactory
cited in response to
and why?
• Clinicians'
answer
that no two patients will presen t exactly the same.
The main specific outcome measures used were pain
and managing patients' problems requires under
drawings by the patient and pain a nd range of motion
standing their unique pain experiences. Therefore.
responses dem onstrated during lumbar spine move
treatment also needs to be based on the patient's
ment. The pain draw ing is particularly important as it
individual responses to ex a mination and
i n d i cates the extent of the pain experienced. Harms
gressed according to measurable outcomes. Con
Ringdahl ( 1986). Kellgren ( 1977) and Kuslich et a!.
sequently, interpretation of these examinati.on
pro
(1991) have all described that increasing stimulus
findings and outcomes. and hence the on going
incre a ses pain intensity and the radiation of pain.
selection of treatment for
with the radi ation usually tr aveling distally;
requires practitioner skills in clinical reasoning.
on
Copyrighted Material
a
given individual. still
CLI N I CAL R EASON I N G I N AC T I O N : C A S E STU D I ES FROM EXP E RT M A N UA L THERA P I STS
E)i""ii,iim"irfirfB9i,I§,'_ • Session 2
lateral llexion were significantly improved. Ten repeti tions of flexion in standing did not produce back or leg symptoms .
(1 day later)
Jamie's exercise was again reviewed. Extension in
Jamie reported a moderate reduction in the severity of
lying produced a 'strain-like' discomfort across the
his pain the next day. On questioning regarding the
lumbar spine and this was not influenced by position
location of the pain. he reported that the pain was no
ing the pelvis to the left. As he no longer reported uni
longer radiating into the leg and was more localized
lateral symptoms and because displacing the pelvis
to the right lower lumbar region. He also reported
to the left no longer altered the symptom response.
experiencing an ache and stiffness across his lumbar
instructions were given to discontinue shifting the
spine. which he was able to relieve by doing the pre
pelvis while performing the exercise. The extension
scribed exercises (i .e. extension in lying with his pelvis
in lying exercise was further modif'ted by asking the
displaced to the left). He could now complete daily
patient to breathe out at the limit of the movement.
activities with considerably less discomfort. and he
The aim of this request was to achieve a slightly
was sleeping better. He had been compliant with the
greater range of extension by providing a form of
instructions given and had performed the exercises
'self-overpressure' to the movement.
2 hourly. avoided flexing and used the lumbar roll when sitting. On examination, there was no evidence of a lateral shift. Although the lumbar spine remained flattened.
• Session 4 (1
week after initial
assessment)
there was a 50% increase in the range of lumbar
Jamie reported feeling Significantly improved. He had
spine extension. Lateral flexion to the right remained
been able to move more freely. stay upright for longer
limited by 2 5%. The patient was asked to demonstrate
periods and sit for a considerably longer time. When
how he had been performing the extension in lying
questioned regarding the effect of coughing and sneez
exercise. His technique was correct. He reported right
ing, he reported that he no longer experienced any
lumbar spine pain at rest. which shifted to the centre
pain. Occasionally he was reminded of the central
of his back and was then abolished after 10 repeti
back pain when he attempted to perform an activity
tions of extension in lying with his pelvis displaced
in flexion, otherwise he was experiencing minimal or
to the left. The pain remained abolished when the
no pain.
patient returned to the standing position and walked about for a few minutes.
On examination. there was no lateral shift present. In standing, the only lumbar spine movement that
Jamie was advised to continue performing the
reproduced pain and remained limited was flexion.
exercise on a 2 hourly basis, and to continue sitting
This movement reproduced back pain at the mid
for short periods only. utilizing the lumbar support,
thigh position. However, when flexion was performed
and to avoid flexion movements.
repeatedly the pain did not worsen. Flexion in lying also reproduced central back pain at the end of the
• Session 3 (2
available range, but the pain did not increase. spread
days after initial
or remain after the movement ceased.
assessment)
The patient was informed that the next progres
The patient reported experiencing no thigh or but
sion of treatment was to restore his flexion mobility.
tock pain but continued to experience
ache across
This needed to be introduced carefully so as not to
the lumbar spine and a sensation of stiffness. He
cause an exacerbation of the original symptoms. His
an
stated that he no longer felt the need to take medica
home exercises were now to include extension in
tion for the pain and there was less discomfort sitting
lying (10 repetitions) . flexion in lying (10 repetitions).
and standing. The exercises were becoming easier
followed again with extension in lying (10 rep
to perform and he had been able to carry them out
etitions) . This sequence was to be performed 2 hourly
regularly.
if possible. The patient was given warnings to moni
On examination. there was no evidence of a lateral
tor the location and frequency of the pain and to dis
lordosis
continue the llexion exercise if it was causing an
in standing. The range of both extension and right
aggravation of the symptoms. Extension in standing
shift and the lumbar spine now exhibited
a
Copyrighted Material
14 SELF-M ANAG E MENT IN A PATIENT WITH LOW BACK AND LEG PAIN
was to be used as a preventative stretch after any
Ilexion
activity and after prolonged sitting. Main
tenance of
a
lumbar lordosis when sitting was to be
of s pinal mobility evident. with no reprod uc ti on of sym ptom s The performance of 30 repeated Ilexion
continued.
.
At t h is point Jamie was advised he could resume
work on reduced hours doing selected duties. but
with
Examination did not reveal the presence of a lat eral sh ift or Ilexion deformity. There was a good range
movements in standing did not reproduce any s y mp
toms or subsequently cause any di ffi cu lty with exten
sion. Flex io n and extension in lying were both full
no lifting or carrying permitted.
ran ge and p ai n free The patient demon strated that -
.
he was able to correct his stand ing and sitting pos
• Session 5 (2 weeks after initial assessment)
tures and maintain these pOSitions for a lengthy period.
The patient repor ted he had returned to work without any effect on the symptom s. He had been symptom free except for when he sat incorrectly or had to stay in a semi-llexed position to perform a task at work.
A prophyla c tic self-management programm e was discussed with Jamie, consisting of: • regular perfo rmance of ,
The sensation he then experienced was a stiffness
across the back. which made it sligh tly difficult t o
straighten.
This feeling dissipated rapid ly when he
performed extension stretches in standing In add-·
lifting • continued use of a lumbar support when sitting • continued performance of a set of 10 extension in
lying exercises morning and night
.
ition. t h ere was no longer any dis comfo rt experienced
with the t1exion in ly ing exercise and he felt that
• at the first sign of rec ur rence ,
repeat the sequence
of exercises that led to recovery.
hi s Ilexion ra n ge of motion in sta n ding was back to normal for h im
extensi on in sta nd ing
after sitti ng sustained Ilexion. and before and after
At this point Jamie was discharged.
.
REASON IN G D I S C U S S I ON AN D C L I NI CAL REAS O N I N G C OM M E N TARY
II
What was you r prognosis fo r this patient and
with
likely to have a less
your reasons for this progn osis?
favourable
less likely to respond to
repetitive motion are prognosis and are mechanical interventions .
• Clinicians' answer The prognosis for this patient was excellent because of the rap i d centralization of symptoms that had been
• Clinical rea sonin g commentary 1.
achieved after a 5-week history of det eri oratio n and
As discussed in Ch ap ter
his willingness to engage actively in his own self
goal more re adily achieved when patien ts receive
self-management is a
management. Several stu dies have shown that move
appropriate expl an a tion and education regarding
ments or positions that centralize symptoms in
their disabilities or activity/participation restric
patients with low back and leg pain can be used to
tions and associated impairments. Wh en self-man
identify those patients wi th a good prognosis [or a
agement is successfully initiated
successful outcome and may be therapeuti cal ly bene
greater responsibility for their i mme diat e and
fici al (Delitto et al.. 1993: Done lso n et aI., 1990:
on go in g health care. leadin g to. as identified here,
Erhard et al.. 1994: Long. 1995: Karas et al.. 1997:
a
Sull(a et al.
.
1998:
Werneke et
al..
1999: Williams
.
patients take
be tter prognosis. Self-management has clearly
featured strong ly thro u ghout this
c as e ,
both with
et al.. 1991). Conversely, pat ients whose symptoms
r esp e ct to the primary treatment and preve nti o n of
fail to centralize or whose symptoms peripheralize
recurrence.
Copyrighted Material
C L I N I C A L REASO N I N G I N ACTI O N : C AS E STU D I ES F RO M E X P E RT M A N U A L T H E R A P I STS
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Williams. van
1 1 8 5- 1 1 9 1 .
Wyk e. B . ( 1 9 8 0 ) . N e u rolog ica l aspects o f l o w bac k p a i n . In T h e Lumba r Spine and Back Pain ( M . J ay s o n . cd . )
p a i n and s c i atic a . A report of pai n
p p . 2 6 5- 3 0 9 . Tu n bri dge vVe l i s .
Medcalf. R . ( 1 9 9 1 ) . P a i n response
response to tissue stimulation d u ri ng
UK : P i t m a n lv! e d i c a l .
sagi tta l end ra nge m o ti o n : a
opera t i o n s o n the lumbar spine u s i ng
Done l s o n . to
Copyrighted Material
e ran i ove rte b ral dysfu n cti o n fo l l owi n g a m oto r ve h i c l e ac c i d e n t Ert Pettm an
�
SU BJ E C TIV E E XAMINAT I ON
Amy, a 3 5 -year-old full-ti me medical re cep t i on is t ,
pres en ted with upper cer v ic a l pain and he ada ches of v a ryi n g i ntensi ty, When a s ked to describe the
headaches, she i n dica ted they were most often bil at eral over the subocci pi t a l regio n , However, for th e last 2 m on ths th ere had been an i n c re a sin g te ndency for
the pain to spread to beh ind
the left eyeb a l l when
exacerbated (Fig, 1 5 , 1 ) , She had no ot he r compl ai n ts o f symptoms or phys i ca l dy sfun ction in
a ny other a reas, There h a d been
n o d i ffi cu l t ies with s pe ec h or swal low i n g , and sme l l and ,ta ste were u na ffe c te d , A my also denied any paraesthesi a or n u m bn ess in the l imbs, trunk , face or mouth or any dizziness, blad der problems, loss of bal a n ce , nausea, vis u a l disturbances or hearin g loss.
The primary aggravating factor was Amy's work , especially those tasks that i nvolved look i n g dow n , such as ty ping an d rea di n g . S h e also reported th at looking over her l e ft s houlder wh ile driv i n g was par ticula rly difficu l t . Tu r n i n g her h e ad to the right was very sti[]' but not p a i n fu \ . In the last month , she had noted that looking over her left shoulder while
driving, if
repeated frequently, could bring on her
headache and left eye p ain .
Fig, 1 5 . 1
Pat i e nt's p a i n diagra m .
Pain could be slowly rel ie ve d b y lying supine no
w i th p i l low s. Early mor n i n g was con side r e d the best
time of the day, Invariably the pain would be mi nimal
although it never abated com h ad been h e lpfu l in r edu cing the pai n , but the an ti - i n flam matory medication ( naprox en ) , stopped because of stomach irritation , had not a l tered her symptoms. during the weeke n d ,
pletely. Amy felt that her analgesic med ication
R EASONING DIS CUSSION AN D C LINICA L REASON I NG COMM ENTA RY
D
• Clinician's an swer
What were your initial thoughts about the
huge m o s a ic of p a th o
source(s) of her symptoms? W hat evidence
Head aches can be caus e d by a
supported or negated your hypotheses?
logical con d i tions a n d p hysica l dysfunction s. Much
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21 5
CLI N I CAL REASONIN G IN AC T I ON: CASE STUDI ES F ROM EXPERT MANUAL TH ERAPISTS
more detai led assessment is requ ired ( bot h
in the his
( i ) the symptoms a ppea red to res pond to mecha n
tory a n d the physical ex a m i n a ti o n ) to isola te the
ica l c h anges . Le. consisten tly worse with cer tain
sou rce(s) . However. si m p ly on the basis of the i n for
head/neck activities or postures: and ( i i) the sym p
ma tion thus far. we can begi n to differen tiate between
toms were consistently relieved by avoidi n g p ain
some of the poten tial ca uses .
aggravating activ ities or postures d urin g t he days
Cranial nerves.
From the lack of immediate evidence
o il work and fol lowin g a n ig h t 's rest.
of sign s or symptoms of cranial nerve pathology (e. g. sensor y disturba nces: speech or swal lowing prob lems: facial or oral paraest hesia or numbness: dizzi
• Clinical reasoning commentary
ness . loss of bal ance or nausea : facial paralysis:
Althou gh the clin ical evidence at this early stage
strabismus: pu pil dil ata tio n : etc. ) it was u nlikely there
suggests tbe cerv i cal spine is the most l il<ely so urce
was
of the patien t 's symptoms . t h e clinician is o bvio u sly
a
maj or problem wit h cranial nerve conduction.
Ve rtebrobasilar a rte ry .
Amy 's deni a l of any
dizzi
keeping
an
ope n mind to other possible sources.
ness. nausea . loss of b a l a nce or vis u a l disturba nces.
There is clea rly
as wel l as the a p p aren t absence of dysarthri a . made
ered in this category. i ncluding
i t u n l il<ely that there was a ny involvemen t of the
therapy d i agnoses suc h as menin ge a l tumours. vas
ver tebrobasilar ar tery.
c u lar disorders and den t a l prob lems . This range of
a
wide range of hy potheses consid a typical
ma nu a l
The possibil ity of the u pper cervical
non-musculoskelet a l poten ti a l sources h ighl ig h ts
meninges being the p a i n genera tor was not ru led
the breadth of proposition a l and no n-prop o sitional
Meninges.
(Le.
clinica l
patterns)
ou t at this stage. F lexed positions of the head
craft knowledge
a g grava ted the he ad a ch e . p articula rly wi th the
a p ists must possess . By mainta i n in g
manual
an
ther
open m i n d .
h i ps flexed in sitti ng. wh i le it was relieved by lyi n g
t h e c lin i cian is avoid ing t h e
s u p i n e with no p illow. The absence of any bil a tera l
error of considering too few hypot heses. which may
or q u adri l a teral paraesthesia or numbness and
pote n t i a lly
of
sign i fi cant
nig h t
pain
s uggested
th at
a ny
meningeal involve m e n t was p rob ably not associ a ted with a sp a ce-occu pyin g lesion (e. g . tumour ) .
bias
the
com m o n
reason i n g
d iagn ostic deCision-m a k i n g
process and related ma n agemen t decisio n s . A nother common reasoning error i s t o neglect negating features for hypotheses considered (con fir
T h e s y mptoms m a y be
mation bias ) . However. in this case. i t is apparent that
c a used by tri gem in al reference as this nerve serves
the clinician is alert to the absence of su pportive fmd
Te mporo m a n d i b u lar joint.
most o f the head stru ctu res . Si nce observ a ti on and
ings (Le. negative featu res) for some hypoth eses and
t h e his tor y so far h ave not indicated a cra n i a l
does not
n er ve V dysfu nction . other potential structures
dence ( L e . positive features) . This requ i res substa n
c o u ld i n c l ude the temporo m a n d i b u l a r
j Oint ( a n d
just
weight t he presence of supportive evi
ti al. rellective c linica l experience to l earn and
be able
rel a te d m u scles) and the teeth . However. A my did
to generate ' expected' cues or clinica l Ilndings associ
not refer to any
ated wit h various patterns of presentation.
dental
discom fo rt or recent
It is al so o f i n terest to n ote t h a t
den tistry.
even
at this
With the histo r y of tinnitus . it was pos
ear ly stage of the clinica l encoun ter the c l i n ician
sible t h a t a middle ear disorder mi gh t be i nvo lved:
feels he has suffic i e n t i n forma tion to begin to ' d i f
however the absence of any earache or loss of bal
fere ntiate ' bet ween hypotheses as to t he source of
Middle ear.
a nce made the middle ear a n u n likely candid a te.
the pain. That is. a s wel l
as
t h e obv io u s prod uction
Amy 's account of the behav iour o f
of a good va riety of h y pot heses i n this category.
t h e p a i n strongly su ggested t hat the headaches
the reason i n g process clearly a l so involves the
were of cervical (m uscu loskeletal) origin because
ranking of hypotheses .
Ce rvical spi n e .
Amy had been i nvo l ved i n a rear-end motor vehic le
the sa me size as her own ve hic l e travelling at approx i
accident 1 year prev i o u s ly. S h e was the driver of the
ma tely
car and was stationar y at tra ffic lights. with her head
t h ree- point seat belt and her head res traint was at her
pas
eye level. al thou gh she tended to drive with her back
sen ger. She was hit w i t h o u t wa r n i n g by a c a r a b ou t
not in con tact. w i t h t he sea t ( L e. lea nin g forwa rd ) .
turned sl igh tly to the rig h t convers i n g with her
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30
km /h . S he sta t ed that s he was wearing a
1 5 C RA N I OV E RT E B RA L DYS F U N CT I O N F O L LOWI N G A M OTO R V E H I C L E AC C I D E N T
A my den ied a ny i mmed iate p a i n or dizziness fol low
within 1 month. In itially. a nalgesics had little effect but
ing impact and her head did not strike a ny t h i n g
anti-infl ammatory medication re l ieved her symptoms
w i t h i n t h e car. She remai n ed con scious a n d alert.
sufficiently for her to be able to con tin u e workin g . Amy
Occipi tofron tal
head aches
and
tinnitu s
began
within a few hours after the im pact. Apart from
tem
had received h igh-vel ocity man i p ulative trea tmen ts from a chiropractor ( 2 months earlier) an d also a phys
( 1 month e arlier) . On both occasions. the had dramatically increased her symptoms
porary (1 month d u raLion) lower neck and bilateral
iotherapist
shoulder girdle pain. there were no other complaints
treatment
fo llOwing
and took several days to abate.
the
The
accident.
marked ly
headaches
2 -week
Amy reported a healthy childhood and there was no
a bse nce from work immediate ly after the accident.
prior history of inj ury or disease. nor any re lev ant famil
decreased but did not: clisappear
during
a
U pon return i n g to work. the headaches rapidly became
ial history. She had no current medical complaints .
worse. al thou g h the tinnitus had resol ved completely
Presently she was unmarried and had no children.
R EASO N I N G D I S C U S S I O N A N D C L I N I CA L R EASO N I N G C O M M E N TA RY
D
What d i d yo u th i n k was the cause of the
present, which the manipulation increases. or the
ti n n i t u s !
manipulation forces the j oint to move into
a
hypermo
bile or segmen ta lly unstable part of the range of
• C l i n i c i a n 's an swe r
motio n . Since no recen t tra uma was reported , the most
T i n n itus can have a n u mber o f vary i n g causes. These can be i n tracra n i a l . such as a n aco ustic neuroma of cran i a l nerve VIII or d a mage to the cochlea I nerve or organ o f Corti (e. g . related to a fractured temporal bone) . Tin n itus can also have extracra n i a l causes and th ese fa l l i n to two categorie s : middle ear i n fections or da mage to the ty mpanic memb rane . and central exci tation of
the tri geminal n e r ve complex leading to
hyper tonus of the tensor tympan i . A my denied a ny hearing loss , dizzi ness or loss o f bala nce so this Si g n i fi c a n tly d ecreases
the lil<e lihood
of i n tracra n i a l causes, middle ear i n fections o r tym panic membra n e d a ma ge
.
The most l ike ly c a u s e wo u ld be central excitation from repe titive o r unrem i t t i n g input [rom a (dam
likely c a u se was that o f
an
adaptively hypermobile or
segmentally u n stable j oint. This w U I , o f cou rse. need to be confIrmed later in the p hy sical exami n a ti o n . G iven t h a t s h e had n o w had consta n t headaches fo r 1 year and any soft t i s s u e i n j u r y from the motor ve h i c l e accident wo u l d h ave been expected to 'heal' in that ti m e , what did yo u hypothe s i ze was m a i n ta i n i ng h e r headaches ! D i d you explore the poss i b i l i ty of a n y n o n - p hysical contributing facto rs!
• C l i n i c i a n 's answe r The expectation of healing presu pposes that the d am
t he ti n n i tus itse lf derived fro m hypertonus of t he ten
leaves the potential for hea l ing to clear challenges to this supposi tion, amputation bei n g the most o bvious, but grade 3 l iga
sor ty m pa n i . Since A my d e n ied any head tra um a a n d
mentous tears and u n treated displaced fractures are
aged ) str uct u r e within the trigeminal co mplex , with
age done to tissues
occur. There are
w a s not comp l a i n i n g o f a ny j aw p a i n , toothache o r
fur ther exa mples of tissue i nj uries that d o not ' heal ' . Of
eara che, t h e n t h e
those that can heal . the most common type of heali n g
probable s o u rce of t h e t i n n i tus
was the craniovertebra l region ( a tla nto-occ ipita l or atl anto a x i a l j o i nts) .
traumatic
' .
arthri tis,
if
one
will be generalized sue. with
re s u l tan t
fibrosis throughout the capsular tis
loss of motion and decreased sensi
tivHy, i . e . u l timately a painless sLiff j oint. HabiLual .
• C l i n i c i a n 's an swe r symptoms
follOWing
accepts that the capsu le has been damaged then there
H ow d i d you i nterpret the u n favo u ra b l e
of
'
Therefore.
responses to th e p revi o u s neck m a n i p u l ati o n s !
Exacerb ation
in adu lts must be b y second inten tion
fu nclional movements that would normally require the can
occur
fol lOwing
m a nip u l atio n when ei ther there is tissue damage
lost motion of the damaged j oint
will
determine any
ad aptation to this loss of molion . I n the present case. the
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CLINICAL REASONING IN ACT ION: CASE STUDIES FROM EXPERT MANUAL TH ERAPISTS
necessity for cran iover teb ral l1exion, such as habitu ally looking down at work, would h ave demanded some compensatory movement in a n o ther craniovertebral j o int. At the point that the compensating joint exhausts its ad aptive potential. ( trigeminal ) pain will result. S i nce this was a n u n s ettled i ns u rance c l a i m , pos s i ble impen d i ng litigation was also an o b v i o us factor. However. i n the h i s tory, Amy detai led a very ty pic a l accou nt o f symptom delay fo ll owed by moderate head , neck a n d shoulder girdl e p a in that was relieved by rest from wo rk for a short period of time. Upon retu rn to work, despite
an
increase in symptoms, she remained
at work a nd in add i t i o n admi tted that with i n 2 weeks the lower neck pa i n , shou lder g irdle p a i n and ti n n i tus were
all
totally rel i eve d .
Her c u r re n t symptoms
d id not seem to be exaggerated, appeared to have a mech a n i c a l b a s i s , and A my read i ly a d m i tted to b e i n g ab le to control them with rest. The co nsiste n t and no n-exaggerated response to the p hysical assessment fu r th e r su pported the i m p ression that there were no no n - p hysic a l co ntributi n g factor s .
spine was con sidered t h e most likely source of the patient's p a i n , b u t this hypothesis h a s clearly evolved with more cli n i c a l data. Consideration of the p a t i e n t ' s t i n n i t u s suggested the cranioverte bral region in partic u l a r : the response to prev i o Ll s man ipulation treatment rai sed t h e li ke l i hood o f
a
hypermobile joint: a n d fi n a l ly the c h ro n i c n a ture o f the pro blem and i ts mech a n i c a l behaviour sug gested the presence of a n adj acen t hypomo b i l e j o i n t fac i l i tat i n g hypermobil ity of the symptomatic j o i n t . The spec ifi c i t y of this hypothesis is typical of an
expert c l i n ician and the prod uct of s i g n ifica n t
reflective practice. Wh i l e manu a l therapists a re traditi o n a l ly wel l aware o f the i mportance of considering, assessing a n d managing physical c o n t r i b u ti n g factors to patients' activity/participation restri cti o n s . symp toms and i mpairments.
as
h i gh l i g h ted i n Ch apter
1 . exp l i c i t atte n tion to potenti al psyc hosocial con tributing fac tors has h i sto rica lly been less formal . o ften
a
tacit impression gC:l i n ed through the cou rse
o f other assessmen t s . Psychosoc i a l scree n i n g ( e . g . patients' perspec tives of t heir ex peri ences, i n c l ud
• Clinical reasoning com mentary The res ponses to these questions show
ing their u n dersta n d i n g , bel iefs, fee l i n g s and a t tri
progres
b u t i o n s ) i s i n c reasingly being recogn ized as an
s ive refi n e m e n t o f the primary d i agnostic hy poth
essen ti a l element of t h e ma n u a l t herapis t ' s assess
a
esi s , wh i c h incorpora tes considera t i o n o f both the
m e n t . The c l i n i c i a n ' s hy pothesis i n response t o the
structural s o u rce o f the symptoms and the associ
secon d part of Question 3 ( e . g . ' t h ere were no non
ated symptomatic and c o n tribu ti n g i m p a i r m e n t s .
physical contTibuling factors' ) i llustrates his aware
The a n s wer to Q u e s t i o n 1 i n d icated the cer v i c a l
ness and atte n t i o n to t h is impor t a n t
tEl
a re a .
P H YS I CA L EXAM I N AT I O N
Observation
• g ross flexion a n d exten sion appeared fu l l ra nge
A my a d opted an obvious forward h e a d postu re a nd this was brought to her attentio n . S h e stated that s h e had b e e n made aware of t h i s prev i o u s l y b u t th at
a n d was p a i n -free • gross side bending appeared fu l l range a n d was p a i n - Iree bi latera l ly.
attempted correcti on of her posture had always led to
On the basis of these tl n d in g s , an assessment of range
increased h e adaches.
of motion was again performed , but with emphasis on local izi n g motion to t h e cra n i overtebra l j O in ts :
Cervical active movements
• from neutral ( pa t i e n t s i t t i n g LIp stra i g h t ) , cran
G ross movements were assessed :
iover te bral llex ion ( c h i n to i\d a m ' s app l e ' )
• rotation to t h e right was li m i ted 5 0 % a n d pai nless
the left-sided suboccipita l p a i n
o n overpressure • rota t i o n to the l e ft was fu ll ra nge a nd reprod uced the suboccipital p a i n with overpres s u re
wa s
completely abse n t a n d overpres s u re re prod u ced • cra n i ove r te bral pa i n - rree
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exte nsi on
was
fu ll
ra nge
and
1 5 C RA N I OV E RT E BRAL DYS F U N C T I O N F O L L OW I N G A M OTO R V E H I C L E AC C I D E N T
• c r a n i overtebra l
side
bend i n g
to
the
l e ft
was
flex i o n reproduced left s u boccipi t a l p a i n ; right
o deg rees a n d p a i n less o n overpressure. whereas
side
rig h t side bending appea red fu l l ra nge a nd was
other
ben d i n g
p a i n - free.
symptoms
m o t i o n i n c reased
motions
prod u ced
no
this p a i n c h a n ge
in
and the
• a n te r i o r tra n sl a t i o n o f atlas a n d a x i s o n a fi xed occiput ( p o s terior tra n s l a t i o n of atl a n to-occipita l
C o m p ress i o n and tract i o n
j o int) reproduced left s u boccipi ta l p a in : if the stress
M a nu a l com press i o n throu g h the head did n o t alter
was m a i n tained. the l e ft-sided retro-o c u l a r p a i n
A my ' s sy mpto m s . but sustai ned manual trac tion
w a s reprod uced.
i n creased the s u bocc i p i t a l p a i n .
A l l tests were n eg a t i ve fo r i n s t a b i l i ty. No cord o r ve r te b r o b a s i l ar
a r tery
signs
or
symptoms
we re
provo ked .
N e u ro l ogical tests Key upper l i mb muscle tests . ski n s e n s a t i o n a n d rel1 exes were a l l n o rm a l . Lower l i mb rel1exes. i n cl u d
C o m b i n ed m ove m e n t testi n g with
i n g c l o n u s a n d B a b i n sk i . were a l l norma l .
overpressu re Ro tation was a g a i n performed. t h i s time in c r a n iover tebra i lle x i o n ( c h i n tuck) and then in c ra n i ove r te b r a l
N e u ral mob i l i ty tests
exten s i o n ( c h i n poke ) .
The sl u m p test was nega tive : a l th o u gh subocci p i t a l pa i n co u l d be reproduced b y craniovertebr a l l1exio n
I n c r a n iove r te b r a i llex i o n t h e left subocci p i t a l p a i n w a s reprod uced . b u t :
t h i s p a i n w a s n o t i n l1 u enced b y a ny lower limb motio n . The su boccipita l pain was also not i n l1 u e nced by perfo r m a n ce o f the upper l i m b n e u r a l te n s i o n /
• w i t h the a d d ition o f rig h t rotatio n . there w a s
a
s l i g h t decrease in this p a i n a n d the l i m i ta ti o n o f
m o b i l ity t e s t w i t h t h e h e a d m a i n t a ined i n craniover
r i g h t rotation (seen i n n e u tra l ) i n c reased to 7 5 %
tebra l l1 ex i o n .
( o f l e ft rotation i n n e utral) ; t h e re was n o i ncreased p a i n with overpress u re
Pass ive i n te rve rte b ral j o i n t m oti o n a n d stab i l i ty tests
( C 2-C 3
occi p i t a l
pain
g r a d u a l ly
increased
u n til
Amy
stopped mov i n g . bec a u se of t h e p a i n . w i t h a 1 0 'X,
Pass ive range o f m o t i o n was cons idered norm a l in all segments
• w i t h the a d d i t i o n of rotation to the l eft . the left su b
to C 7-T l ) .
No
i n stabi l i ty
was
loss o f left rotation • wi t h the a d d ition o f overpres s u re to rotation to the left . a ful l r a n g e of motion was g a i ned . with a s i g
de tected .
n i fic a n t i ncrease i n subocc i p i ta l p a i n ; s l o wly. the overpressure h a d
C ra n i ove rte b ral j o i n t stress tests
a
if
performed
normal e n d-feel . but
i f performed more rapidly. a n e nd-feel o f s p a s m w a s
The I'o l lowing tests were perfo rmed o n the c ra n i ove r tebral j o i n ts :
evoked . In cra niover teb ral exte nsion . both rotation to the left
• traction i n c ra n i ove rtebral l1ex i o n : c ra n i over tebral l1 exion reprod u ced left subocci p i t a l pain a n d trac
a n d ri g h t were ful l range with no p a i n e l i c i ted o n overpressure.
tion fu rther i n crea sed i t • a n terior transl a t i o n o f occi p u t o n fixed a t l a s did n o t reprod u ce sy mptoms • l a teral tra n s l a t i o n of the atla n to-ax i a l j o i nt did n o t reproduce symptoms reproduce symptoms ion.
l igament neu tral
tests and
A fter overpress ure o f the c o m b i n e d ac tive move m e n t s was r e l e a s e d . i s o m e tr i c m u scle resista nc e was g iven
• a n terior tra n s l a t i o n of atlas o n fixed axis d id n o t • alar
I so m etric m u s c l e tests
to the a nt a go n i s tic (io relation to the moveme n t ) m u scles whi l e i n
( b i l atera l ly exten s io n ) :
tes ted
in
Jlex
cran i over tebral
their
optima l ly l e n g t h e n e d p o s i ti o n .
Isometric muscle testi n g n e i ther aggravated n o r a l le viated Amy ' s symptoms.
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I
CLINI CAL REASONING IN ACT I ON: CASE STUDIES FROM EXPERT M A N UAL T H ERAPI STS
R E A S O N I N G D I S C U S S I O N A N D C L I N I C AL REASO N I N G C O M M E N TA RY
a
Did t h e fi n di ngs at this point suggest a c l i n ical patte rn that m ig h t i mplicate c e r tain structures ?
poss i b ly either the left i n ferior obl ique o r the righ t superior oblique. The
Uppe r ce rvical joints .
• Clinician's answer
motions
Restricted or p a i n fu l neck movem e n t c a n h ave several possible c a u ses. Al t h o u g h acute
tra u m a ti c ar thritis of a zygapophy seal j o i n t m i g h t prese n t w i t h a s i g n i fi c a n t l o s s of rotati o n . the loss rotation
that head/neck Amy 's p a i n
i nculpates t h e neck. T h e upper three j o i n ts share a common sensory nerve su pply from the cervical nucleus of the trigemin a l complex. In parti c u l ar, the
Zygapop hyseal joint dysfu n ction .
of
fact
reproduced or agg ravated
is
accommod ated
fo r w i t h i n
3-6
m o n ths post-tra u m a . pres u m ab ly by decompe n s a t i o n thro u g hout the rest of t h e spi n e : t h a t i s . res i d u a l l o s s of rotation from a c h ronic zygap o p hy sea l j o i n t l e s i o n
is m i n i m a l
gross unilateral loss of rotation suggested a cra nio vertebral j oint dysfunction. responsible fo r up to
50%
as these joints are
of ava ilable head rotation
( Dvorak et al .. 1 9 8 8 ) . In this case. the magnitude of the rotatio nal loss means that it co u ld never be decompensated . no matter how chronic the i n j u ry. Combined motio n s usi n g Il exion and extension may
( ' decompen sati o n '
help to di ffere n tiate fu r ther the responsible cra niover
refers t o neurophysio logic a l and/or biomec h a n ic a l
tebral j o i nt. The reason i n g behind this is t h a t Ilexion
s tra teg ies employed by the body t o make itself
and ex ten s i o n o f the a tl a n to-occ i p i t a l jOint can a lso
more fu nctional ly e ffi c i e n t) . F u r t her. from c l inical
be viewed biomechanically as a n terior ro U with poster
experi ence. the lesion wo uld be a ssoci ated with a
i o r glide (Fig. 1 5 . 2 ) a n d posterior roll with a n terior
s i g n i fi c a n t loss of side bend i n g t h a t cou ld never be compe n s a ted. There was n o i n d ication of a s i g n i fi c a n t loss o f side bend i n g in this case. Cervical
spondylosis.
Generalized
degenerative
c h a n ges w i l l lead to a m a rked loss o f rotatio n . However. t h e loss occurs as p a r t of a n articul ar pa tte r n of res tricti o n . which would i nvo lve a n e q u a l l i mi tatio n o f side bend i n g . I n a d d i t i o n . per s o n a l clinic a l observations i ndicate that restric tions o f motion fro m degenera tive spondy l o s i s are
I'"
more l ikely to be b i l a tera l . Muscle lesi o n .
r
I Ir .
'\ \ I
Si nce the l i mitation o f r i g h t rotation
'
motion was i n creased with c r a n iovertebra i llex ion . the sternomasto i d . trapezius or posterior s ubOCCip ital muscles could h ave been respo n s i b le. Because the isometric muscle tests were negative i n terms of pain reproducti o n . one c a n assume th a t if muscle ti ssue were responsible it must be chronically scarred and con tracted . given the t i me el apsed since the a c c i d e n t . I f the o ffend i n g muscle was s h o r tened by scarri nglftbros i s . the only detec table sign wou ld be a l oss of moti o n . The ster nomastoid a n d trapezius m u scles were u n l ike ly culprits because there was no h is tory of any p a i n i n the a n terolate r a l region o f the n e c k . The d e g ree a nd d i rection of lost motion s u gges ted i t wo u l d h nve to be a suboccipital
Fig. 1 5 . 2
m u s c l e wi th a s i g n i fica n t rota t i o n a l l i ne of fo rce.
c o n d y l e s of t h e O C C i p u t g l i d e poste r i orly.
Copyrighted Material
D u r i n g atlantO-O C C i p i ta l j o i n t fl e x i o n , both
1 5 C RAN I OV E RT E B RA L DYS F U N C T I O N F O L L OW I N G A M OTO R V E H I C L E ACC I D E N T
/,
Fig. 1 5 . 3
D u ri ng atlanto-occ i p i ta l joint exte n s i o n .
b o t h condyles o f t h e o c c i p u t g l i d e anterio rly. F i g . 1 5 .4
At the atl a n to-occi pita l j o i nts d u r i ng rotation
of the head to the right, the right o c c i p ita l c o n d y l e will .
glide ( F i g . 1 5 . 3 ) respectively. S i mi l a rly, d u r i n g right rotati o n , for ex a mple, there wo u l d be a correspo n d i n g
g l i d e poste r i orly a n d the l eft occip ita l c o n d y l e w i l l g l i d e ante r i o rly.
a n terior glide of t h e left occipital condyle a n d a poster ior gl ide o f the right occi p i ta l con dyle ( F i g . 1 5 . 4 ) . B y i n itiating the motion with flex i o n , s o me of t he av ai lable posterior gl ide w i t hin both atlan to-occipital j oi n ts is ta ken up. If a restriction o f posterior g l i d e were t o exist w i thin the r i g h t j o i n t , then right rota ti o n , which u ti l i zes further posterior gl i d i n g of the right occi pital condyle, wo u l d appear to i ncrease i n i ts l i m i tation . However, flexion and extension of the atlanto-axial joint do not share any of the s ame biomechanical com pone n ts as rotation of this j o int. For exam ple, right rota tion occurs
as a
resu lt of an anteroinferior glide of the
left C 1 condyle (on C2 ) and a simultaneous posteroinfe rior gl ide of t he right C 1 condyle (on C 2 l . During flexion and exten sion, there is a bilateral and simultaneous anterior and posterior roll ( respectively) only of the C1 condyles on the C2 condyles (reCiprocal ly male/male) (Kapa n dj i, 1 9 74 ; Werne, 1 9 5 8 ) . Tran slation or gl iding
Fig. 1 5 . 5
At the atla nto-ax i a l j o i n ts d u r i n g fl e x i o n , the
co nvex condyles of the atlas rol l a n terio rly. T h e re i s n o
is normally pro h ibited by the dens/tTansverse ligament
s ign ificant anterior o r posterior g l i d e o n the c o n d y l e s o f
restraint mechanism ( F i g. 1 5 . 5 ) . Therefore, flexion and
the a x i s .
Copyrighted Material
C L I N I CA L REAS O N I N G I N ACT I O N : C AS E STU D I ES FROM EX P E RT M A N U A L T H E R A P I STS
extension can have no direct effect o n rota tion at the atla n to-axial j Oints. Co nsequ ently, i f there i s a n obv i o u s cha nge i n
• C l i n ical
reaso n i n g c o m m e ntary
A well-orga nized and accessible knowledge base is
a
the ava i l a b l e rotation at the cra n i overtebra l j o i n ts
vital element o f the reasoning process and is espe
(eit h e r better or wo rse) when com b ined with Ilexion
ci alJy appl ied by the expert in t he rec o gn i tion of cli n
or ex ten s i o n , the restricti o n lies with i n a n a tl a n to occ i p i t a l j oi n t . If. ho weve r, the ro ta ti o n range of
ical pattern s and their associa ted actions. C l i n ic a l knowled ge comprises both proposit ional and non
motion does not a l ter d u ri n g tlexion or exte n s i o n ,
propositional i n formation . the latter i nclud ing pro
then t h e restriction
lies
wi t h i n
an
a tl a nto-a x i a l
joi nt.
fes s ion a l craft or procedural knowledge a nd person al
knowledge. The thi n k i n g evident i n t his
P a i n w a s also provoked d uring i nstab il i ty testing
vides
a
a n swer
pro
very good exa mp le of t h e seamless int.egra
i nvol v ing craniover tebral fl ex ion . po s sibly suggesting
t ion of p ropos i t i o na l know l e d ge (e.g. biomechanics
inert tis s u e ir ri tation . This response co u ld h ave been
and st.ructura l anatomy of the cervical spi ne and rel a ted musculature) and professiona l craft knowl ed ge ( e . g . concept o f deco mpensation a n d t h e applicat ion of c o mbi n e d movement exa m i n a t i o n findings) characteristic of t h e expert clinici a n .
comin g from the atl a n to-occipi tal an d /or atla n t o-ax i a l j o i n t ca psu les , the posterior atlanto-occi p i t a l li ga
ment, the po s t e r i or atlan to-occ ipital membra ne or the atla n to-axial j o i n t ligamentum Il av u m .
T h e i n formation ga i n ed in t h e pre l i mi na ry p hy s i c a l ex ami n ation w a s ex tended b y further pass ive tests .
Passi ve i n te rve rte b ral m otion tests fo r the c ran i overteb ral j o i nts With the head pos i ti o n ed at the l i m i t of tl exi o n and ri gh t rota t i o n : • t h e r i g h t a t l a n to-occ i p i ta l j o i n t w a s tested with
an
a n terior glide of the ri gh t con dyle of the a t l a s : th is was met with a firm, u nyieldi n g end-feel and was p a i n - free ( F i g . 1 5 . 6 )
F i g. 1 5 .6
Ove r p re s s u re o f right atlanto-occ i p i tal j o i n t
fl e x i o n i s g i v e n by fixing the o c c i p u t at t h e l i m i t of c ra n i overtebral fl e x i o n and right rotation. a n d gl i d i ng the right condyle of the atlas anteriorly.
• the atla n to-axial j oi nts were tested with a n antero su per i o r glide of the r ig h t con dyle of the axis u nder a fi xed atlas ( F i g . 1 5 . 7 ) . a n d a n a n te ro i n fe rior gl ide of the l e ft condy le of t h e a t l a s on a fixed
su bocc ip i ta l p a i n was i ncrease d . with the retro orbital pain also reproduced • when the a tlas was fixed a nd the l e ft occipi ta l
a xis ( F i g . 1 5 . 8 ) : b oth showed normal ava i l able
condyle of
glide a n d were p a i n-fre e.
moved a n teriorl y, there was a ma rked decrea se i n
Wi th the head pos itioned a t the l i mi t of left rotati o n in ll ex i o n :
the left a tl an to -o c ci p i ta l j o i n t was
Amy 's pain • the atl a n to-axia l j o i n ts were tes ted with an a n t er o superior gl i de of the left condyle or t b e a x i s u n d er a
• the left atl a n to-occ i p i t a l j o i n t
tested with
an
fixed a t l a s . and an a n tero i n ferior gl ide of t h e r i g h t
a n terior glide of the l e ft condyle of the atla s . under
c o n d y l e of the a tlas o n a ll xed a x i s : b o t h i n d ic a ted
was
a fi xed occi p ut: t h ere was some av a i l a bl e glide
a nor ma l .
before
of p a i n .
a
Jl rm e n d - feel was reache d a n d A my ' s
Copyrighted Material
ll r m end-feel with no reprod uction
1 5 C RA N I OV E RTE B R A L DYS F U N CTI O N F O L LOW I N G A M OTO R V E H I C LE AC C I D EN T
-
+:
Fig. 1 5 . 7
Overpressu re of righ t rotati o n at the right
F ig. 1 5 . 8
Overpressu re of right rotati o n at the left
atl a n to-ax i a l joint is p rod uced by fi xing the atlas a n d g l i d i ng
atlanto-ax i a l j o i nt i s produced by fi x i ng the axis and
the right condyle of the axis a n te r i o r l y a n d s u p e r i o r ly.
g l i d i ng the l eft condyle of the atlas a n te r i o r l y and i nfe riorly.
Tem p o romand i b ular j o int E x a m i n a tion o f the temporoma ncli b u lar j oint was not
were c learly induce d or agg ravated by motion of the
performed because at this stage A my ' s sy mptoms
head a n d neck.
REASONING DIS CUSSION AN D CLI NICA L REASONING COMME N T A RY
II
W hat was the rationale fo r the passi ve motion tests you selected?
In the case of the atl a n to-axial j oi nt , the principles are baSically the same. Amy was asked to move ac tive ly to her mo tion bar rier (right r otation in
• Clinician's answer
fl exi on ) . Right
ro tati on i nvol ves a simu l taneous motion at the ri g h t
Flexion of the a t l a nto-occip i ta l j o i n t is produced by
a n d left j o ints. At the left atl a nto axia l j o int
the s i m u ltaneous motions of an an terior ro ll ( i .e.
cond y le o r the atlas g lides a n terior ly a n d i n feriorly on
-
.
the
while at the rig h t j oint the ri ght
an g u l a r mo tio n ) and a pos terior glide ( i . e . linear
the C 2 con dy le
mo tion) This com bination of movemen ts is stressed
condy le of the a t l a s glides pos teriorly a nd i n feri o r ly.
furthe r in the righ t atlanto occipital j oin t by combin
Therefore, the atl a n to- a x i a l j oi n t s invo lvement in
ing flex ion w i t h ri ght rotation In this case, it was
rig ht rota ti on restricti o n may be tested by apply in g a n
.
-
.
.
'
noted that the restriction o f right ro ta tion a ppeared
a n tero i n ferior glide of the left atl as c o n d y l e on a fixed
to i nc rease with t he combination. The q uestion was
C2 . a n d t hen assessing the a nteros uperior glide of t h e
whether the res tri cti o n had an articu l a r or ex tra
r i g h t C2 c o ndyle under a fi xed a t l a s ( i . e .
art icular (e.g. m u s c le) c a u se. To a n s wer t h i s , Amy
teroinferior gl id e of the ri ght a t l a s con dy le ) If t here is
was asked to flex a nd rotate r i ght to her b a rrier of
any motion avail able in these glides , wh ich in this
motion. At t hat poin t , the head was fixed ( occip ita l
case there w a s , then the atl a nto
condyles ) a n d the ri ght condy le of the atlas was gen
n o t respon sible fo r the loss of active m otion .
a
rel a t ive pos .
-
a xi a l
j o i n t tested is
g l ide o f t he a t l a s
S i mi l a r glides to t hose detailed ab ove may also be
under t h e occ iput i s the same as a posterior glide of
used to stress a j oint s motion at the end of ra n ge to
t h e occiput on the a tl a s ) . T h e loss o f j Oi n t glide at the
see whether t he j oi n t may be resp onsible for t he pain .
point of motion restriction con firmed an articu l ar
In this case, the head was a c tively rotated left to the end
hypomob i l i ty.
of range: the passive ra n ge of motion was con s id ered
t ly glided anteriorly ( a n
an teri or
'
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CLI N I C A L REASO N I N G I N ACT I O N : CASE STU D I ES FROM E X P E RT M A N UAL TH E R A P I STS
normal but was p a i n fu l . If the pain is com i ng from a
This hypothesis of a reactive hypermo b i I i ty was
j oi n t then it fo l lows that stressing the j oi n t i n t o its
s u pported by the observation that during combined
motion b arrier wi l l reproduce or aggravate the p a i n
movement tes ting left rotation in llex i o n , althou gh
i f th a t \J a i n origin ates w i thin t h e restrai ning struc
ful l ra nge with slow overpressure, was painfully
tures of j oi n t motion ( i n the absence of isometric
restricted ac tively. The fact that a spasm end-feel was
muscle action ) : that is, the j o i n t caps u le and ca\Jsular
encou n tered when rapid left rotation over pressure
l i gaments.
was attempted was an indication that the compensation was extremely irritable and possibly exceed i n g its
II
What bearing did t h e phys i ca l exa m i nation fi n d i ngs h ave on your wo rking hypoth e s i s as to the s o u rc e of the symptoms a n d p hysical
adaptive poten tial . Whatever the working hypo thes i s , i t m a tters l ittle si nce the key issue was that A my ' s symptoms were reproduced by overp ressure of left atlanto-occipital
i m p a i r m e n ts ?
j oint fl exion (posterior glide) at t he e nd of normal range. S i nce this accompan ies the fI nding of a hypo
• C l i n ician's an swe r
mobile rig h t a tla nto-occi p i t a l j O i n t . logic wou l d d ic
The passive movement tests con firmed that the c a u se
tate
of the motion restriction into right rotation , and
is need e d , i . e . mo bilize right a t l a n to-occipital j o i n t
right rotation i n f1exion. was an i nabil ity of the right
flex ion.
a
correction of this abnormal b i omechanical state
atla nto-occipital j Oint to f1ex . The tests also conflf med th at f1exion of the left atla nto-occi pital j o i n t was the source of A my ' s symptoms ( i . e . posterior glide of the left occipital c o ndyle occur ring d u r i n g f1exi o n and left rotation of the head, exaggerated by anterior trans lation of the left condyle of the atl a s ) . The fInd ings, therefore, su pported the working hypothesis of residual post-traumatic hypomobility of right atlanto-occipital
D
What were yo u r tho ughts regard i ng t h e m e c h a n i s m s i n itia l ly c a u s i n g a n d s u bs e q u e ntly per petuating the pati e n t's symptoms a n d p hys i cal i m pa i rments ?
• C l i n ician's an swer
joint !1exi o n , with d ecompensatory, p a i n fu l hypermo
The onset i nvolved a rear-e n d c o l l ision while station
bility of the left atla n to-occipital j o i n t .
ary and with Amy cau g h t u n awa res . The impact
To expla i n t h i s fu rther. Amy h as an atlan to
velOC i ty of 30 km/h wou l d have l i kely resulted in h i g h
occipital j o i n t that cannot !1ex. I n i t i a lly her compen
acceleration forces. In add i tio n , her he a d w a s rotated
s a t i o n will be to adopt a forward head pos ture : how
to the right and she habitually leaned forward when
ever, her j ob as a recepti onist dema nds cranioverte bral
driv i ng . The momentum m ay. therefore, h ave created
flex ion. To decompens ate for this dysfunction ( i . e . to
a rel ative posterior tra nslatory and right rotational
m a ke f1exi o n more fu n c t i o n a lly efficient) , either the
force within segments of her neck. In particular, if
a tl a n to-axial j oi n ts or the contralateral ( l e ft) a t l a n to
Amy ' s head was posi tioned in f1exion and right rota
occipita l j o i n t mu st adapt to this new bi omec h a n ical
tion a t impact, the right atlanto-occipi tal j oi n t may
d em a n d . It i s lmcer t a i n why the left atlanto-occipital
have been near the end of i ts range of motion . res u l t
joint would h ave decompe nsated rather than the
i n g in trauma to its capsule.
atlan to-axial joints. Perhaps when
The most like ly result of the i njury was a post the right atlanto-occipital joint
tra umatic
ar thritis
of
the
right a t l a n to-occ i p i t a l
became u n a b le to flex or posteriorly glide, the atlas
j O i n t . T h i s is supported b y t h e fa ct t h a t A my could
would have started to p ivo t around this new ' fixed
only get relief d u ri n g periods away from work ( when
point' ( i .e. the fLXated right atlanto-occipital j oin t ) ,
the need for cran iove r tebra l llex ion was reduced ) .
creating a n e w oblique axis o f l1exion/extension a n d
when lyi n g s u p i n e with n o pill ow, a n d by her adop
leading to excessive posterior gliding of t h e left atlanto
tion of a forward head pos ture ( i .e. craniovertebral
occipital j o i n t . This excessive posterior glide may h ave
exte n s ion ) . Co nve rsely, the symptoms were aggra
i ncreased biomec h a n ical stress on the joint caps u le .
vated by head f1exion postures at wo rk. The initial
Thus, m u s c l e spasm w a s in itiated d u r i n g r a p i d motion
rel ief affo rded by a nti-i n f1ammatory meclic ation fu r
to help to safe g u ard the anatomical i n tegrity of the
ther su ggested a s i g n i llc a n t i n ll a mmatory response to
joint capsule and prevent s u b lux ation .
an i nj ury of the atlanto-occipital j O i n t c a psu l e .
Copyrighted Material
1 S C RA N I OV E RT E B RA L DYS FU N CT I O N F O L LOWI N G A M OTO R V E H I C L E AC C I D E N T
Chronic post-inl1ammatory fibrosis of the right atla nto-occipital j O in t capsule probably l imited i ts flex ion . Because o f the demands of her work, decompensa tion of this u n ilateral hypomobili ly ill,ely involved the left atlan to-occipital j o i n t . Eventua lly, the exhausted adaptive potential of the left atlan to-occipital j oint may have given rise to worsening trigemin a l symptoms ( e . g . referred retro-orbital pain representative of the oph
thalmIc d ivision of cra n i a l nerve V). The extreme sensi tivi ty ( i n flamed state) o f the left atlan to-occipi tal j oint was also evidenced by Amy ' s adverse reaction to manipulative treatment (usu ally targeted a t the p a i n fu l dysfunction ) and b y t h e o n s e t o f muscle spasm with combined movements in the physical assessment.
data o n the sen s i tivity a n d spe c i ficity o f most man u a l therapy assessment procedures, clinicians often must rely on extrapolation of biomedical theory ( i n this case, upper cervical j oint kinematics ) and lo gic ( e . g . provocation of symptoms in
ceptive dominant
a
noci
presentation i mplicating local
j oi n t structures as the source of the symptoms ) in order to detect and j ud ge the relev a nce of spec ific p hysical impa irmen ts. Wh il e some argue
that
theory i s not evid en ce ( e . g . Ro th stei n and Scalzi tti. 1 9 9 9 ) . i t is import a n t n o t to d own-p l ay the value of u s i n g established theory to help to m a ke sen se of pat ient findin gs . As long as c l i n icians are criti cal of u nvalidated assessment and management proced ures, and are systematic a nd thoro ugh i n
• C l i n i cal
t h e i r appl ication an d reassessment of i n terven
reason i n g c o mme ntary
tions, then clinical evidence should be a ccepted
Cl i nical decisions should be based on the ava ilable
u n ti l
evidence. However, because there are few research
become available.
such
time a s
higher levels of evidence
E);" rfB9·''§,,• F i rst treatment The ai m o f management was t o m o b i lize t h e r i g h t atlan to-occipital J o i n t i n t o l1exion a n d restore n ormal posture. Follow i n g the p hys ical assess ment, the treat ment plan was ex plained to the patien t , especially the reasons why the ' wro n g ' j o int wo u ld be treated. The i n i ti a l treatme n t then consisted of a sustained stretching mobilization of the right atla nto-occipital j oint i n to the l1exion barrier, using muscle assistance and levering ind irectly t hro u gh the right condyle
F ig. 1 S . 9
of the atlas. For this technique, A my was seated
atlanto-occ i p ital j o i nt. the occiput i s fixed while the atlas
and s l i g h tly slouc hed so as to put the cran iover tebral
is rotated to the l eft.
D u ring m o b i l izati o n of fl e x i o n at the right
j o i n ts i n a more neutral positio n . Amy ' s atlas was pal pated with the l e ft hand and the head was grasped
Nex t . Amy was a sked to turn her head i n to the
with the right hand . S he was asked to relax and the
therapist's chest. wh ich provided resistance to the
head was then passively gu ided through cran ioverte
movement, th u s e l i c i t i n g a n i sometric contractio n .
bral l1ex ion u n t i l the atlas began to move, fol lowed by
B y revers i n g o r i g i n a n d insertion . the s u boccipital
right rotation u n t i l the atlas again began to move. A t
muscles ( m a i n ly l e ft superior oblique) wil l produce
t h is point, t h e nex i on/right rotation m o tion barrier of
left rotation of t h e atlas under the occi p u t . t h a t i s rel
the right atl anta-occipital joint had been reached. The
ative right rotation or the occipu t . A fter a 3 second
a t l as was then gen t ly sec u red with
lum brica l grip
hold. A my was told to relax . A ny subsequent slack
using the left thumb ( posterior to the right transverse
occu rring at the motion b a r rier was tal,en up by the
process of the atlas) and i n dex fi n ger ( a n terior to the
therapist's lert thumb push ing a n teriorly o n the right
a
left tra n sverse process o f the atlas) (Fig.
15.9).
transverse process o f the atlas. This was c o n ti n u ed
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C L I N I C A L R E A S O N I N G I N ACTI O N : CASE STU D I ES F R O M E X P E RT M A N UA L TH E RA P I STS
until no fur ther s l a c k was produced by the i so me tric con trac ti on s .
T h e therapist the n continues: ' Now t h i s time I wan t you ta ke
U p o n reassess m e n t of A my ' s act ive motion, r i g h t
a
breath i n a n d then push up against
my fmge r s a s you b reathe out' . Lowe r thoracic and
rotat io n i n l1ex ion had i ncreased b y a b o u t 2 0 de g r ees .
l u mb a r s p i ne ' tri ck ' movements a re e a s i ly cor rec ted
Craniover tebral l1ex ion itself was less painful. Flexion
l a ter by do i n g the exercise slo uched in a chair. The
sligh tly
i mpo r tant t h i n g here is that the pa tient appreci ates
I n a ddi ti on , A m y w a s i n s tructed t o ex aggerate
The patient is i n structed to practise this exercise as
a nd
left rotation rema ined
p ai n fu l
and
the idea of e levatin g the chest wh i l e brea thin g out.
restricte d . slightly the c h i n tuck actio n when b end i ng fo rwa rd,
o ften as possi b l e d uri n g the d ay.
espec i a l ly o n l i ft i n g . After each treatmen t . exercises
The exerc ise produces active exten sion of the
were also given a i med at i m prov in g the p at i e n t' s
upper thoracic spine and cervicothoracic j u nc tio n
craniover teb ral movement a n d fo rwa r d he a d postu re .
and helps to regain/ma i nta i n cran io ve r t eb ra l flex ion ( "vi th the aid o f g rav i ty ) .
Exerc i se 1 (atl anto-o c c i p i tal fl ex i o n ) Amy w a s inst ructed h o w t o produce cra n iover teb ra l
• Seco n d
treatment
l1exio n and r ig h t rotation in ord er to m a i n ta in a n d
In
per h aps improve upon the motion ga ined by the
j oi n t , A my was advised to take a week 's le ave of
m o b il iza t i o n .
an
attempt t o d esens i t i z e t h e left a tl a nto-occipital
ab senc e fro m wor k . d u ring wh ic h time a seco n d and si m i l ar mo b i l ization treatm e n t was give n . At t he second visit. Amy demonstrated a ll home
Exerc i s e 2 (passive u p per t h o racic
exerc ises wel l . It was decided to i n troduce fur ther exer
exte n s i o n )
cises, whi l e continuing with the previous exerc ises .
S ta ndi n g ab out 6 0 c m away fro m t h e corner o f
a
ro o m . the patient p l aces their hands on adj acent sides of the co r ner. a t about nec k hei g h t . Keeping the c h i n gently tucked i n , the p a t i e n t l e an s forwards trying to place their chest i nto the cor ner.
A my w a s posi ti oned i n s u p i n e ly i ng , k n e e s fl exed over
The effect of this position is to ex tend the upper thora c i c s p i n e p assively and
Exerc i se 4 (active, resi sted c ran ioverte bral flexion)
stretch the pec to ral
a pil l ow and with her head s uppor ted o n a s i n g l e , so ft p i l low of s u fficient h e i g h t for comfort. The therapist's
muscles ( espec i ally pecto r al is minor) , which often
fi n gers were pl ace d under her occ i p u t a nd s he was
become tig ht w i th a forward head posture. This po si
i n s tructed to gen tly move her c h i n toward s her
tion is held for 1 0 sec on ds and relea sed . The exercise
A d a m ' s appl e.
is repea ted at least 10 ti mes per sessi o n . three ti mes a
I f the pati en t perfor m s the motion correctly t he
d ay. It is expl ai n ed to the patie n t that they sho uld
t h er ap ist sho u ld feel a sl i g ht decrease in the weight
make the exerc ise a h a b i t whenever a l1exed posture
of the patien t 's hea d , but the head sh ould not lose
( e . g . des kwork) is a d op te d .
con ta c t w i th th e thera pi s t 's hands. If contac t is lo s t . t h e n the p a tient is flex i n g lower down the neck . The
Exerc i se 3 (re l axed ex p i rat i o n with active u p pe r tho rac i c exte n s i o n )
t h erapist s h o uld also not feel a ny i n creased pressure or we ight th r ou g h the i r h a n d s , a s t h i s wou ld i nd icate the
T h e patient is seated on the ed ge of a treatme nt table
patie n t
is
us i n g extensor
muscles (probably
thoracic) .
with their fee t su p p or ted on a stool. The therapist pl aces a
thu mb and index Hnger in the pa tient 's flfSt inter
costal space and pushes gently downwards. The follow ing instruction is given: 'I wa n t you to p ush your chest
Exerc i se 5 (res i sted cervi coth orac i c and u p p e r thorac i c s p i n e exte n s i o n )
u p aga inst my fi ngers ' . The pa tie nt will i nvari ably com
Continu i n g on from where the previo u s exercise
ply by taki n g a deep breath in. This should be repeated
ended (in cra n i overteb r al flexio n ) , Amy was instructed
a few times so t h at the patient gets the ide a of p u sh ing
to ge n t ly pus h backward s aga i nst the therapi s t 's Hn
their chest upward s against the t herapist's hand .
gers . Provided the pa tien t' s c h i n do e s no t li ft away
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t 5 C RA N I OV E RT E B RA L DYS F U N C T I O N F O LLOW I N G A M OTO R V E H ICLE AC C I D E N T
from thei r throat, this exerc ise resi s t s t h e u p p e r tho
At the third treatmen t , A my enqu i red about the
racic ex tensor muscles . Amy was able to perform this
possibi li ty of j o i n i n g a gym t o rega i n her fo rmer (pre
exerc ise a t home using a pi llow for res istance.
accident) stren g th and fi tness leve l s . Th i s was enco u r
Both exerc ises 4 a nd 5 were performed 10 times
aged b u t o n l y after s h e was taken i n to the cli n i c ' s gym
per set, th ree sets a day i n i t i a l ly. As A my fel t sh-onger
and t a u g h t how to use p ulleys a n d we ig h ts w i t h o u t
and less p a i n fu l . the n umber o f repetitions in a set
compro m i s i n g t h e efficient a n d s a fe neck posture s h e had a c h ieved . B y the fi fth a n d fi n a l tre a t m e n t , she
was i n creased to the poi n t of fatigue.
was p ar ti c i p a t i n g i n a 1 h o u r per day gym progra mme without any a dvers e effects a n d demonstrated a fu l l
• S u b seq uent treatments
r a n g e o f tlex i o n o f t h e r i g h t a t l a n to-occ ipital j o i n t .
Three more similar treatments were given , each a week
S h e had a l s o been working fu l l t i m e for 2 weeks with
apart, until the fu l l range of right atlanto-occipital joint
o u t a ny symptoms . A l t h o u g h the o c c i p i tal pain could
flexio n was achieved . However, as this condition was
s t i l l be somewh at reproduced
one o f chron ic fi brotic hypomobility, regainin g j oint
overpressu re o f left atlanto-occ ipi tal j o int flex i o n ,
(41 1 0 ) with sustained
range of motion was largely dependent on Amy 's home
treatment was c e a s e d on the understa n di n g that Amy
exercise and postural programme.
would c o n t i n ue to self-man age her c o n d i t i o n .
� j
-
D
REASONING DISCUSSION AN D CLINICAL REASONING COMMENTARY It was hypothesized that A my was not going to get
What was the relationship between the patient's fo rward h ead posture and her clinical
fu ncti o n a lly
presentation!
treated , a n d it was ex pected the recovery period ( o f
better
unless
this
dysfunct i o n
was
t h e postural dysfu nction) would b e measu red i n
• Clinician's answer
m o n t h s . A l t ho u g h exerc ises were given primarily a s a
When a fo rward head ( poki n g c h i n ) posture becomes c hro n i c or h abitu a l , i t essentia lly becomes a respira tory dysfunction and must be treated accordingly to reverse its pathological c h a n ges. The accident m ay h ave e l ici ted or contr i b u ted to the patient's habitu a l forward head posture; u n less this was correcte d , pathological seque l a e were more t h a n likely going to occur in the fu ture. T h e most i mmed iate biomechanic al crfect o f this posture is that the local ized flexi o n o f the upper thor
preve n t ative measu re, with o u t correcting the p o s tu re it wou l d have been i mpossi b l e to rega i n fu l l tlexion o f the craniove rtebra l regio n . The exercises a lso helped to strengthen the muscles necessary to m a i n t a i n a n optimally e fficient posture . W hat did you consider was the likely prognosis for this patient!
• Clinician's
answer
acic segments wiU prod uce a depression of the rtrst and
At the i n i tial assess m e n t , it was clear that the r i g h t
second ribs a n teriorly. Th is will effectively i ncrease
atl anto-occipita l j o i n t w a s n o t going to star t moving
load i n g on the anterior chest, increaSing the motor
s p o n t a n eo u s ly and conseque ntly t h e pain from the
recruitment demands o f the diaphragm , even during
a d apting left a t l a n to-occ i p i t a l j o i n t would h ave prob
quiet respiration . The increased motor recruitment
ab ly continued to wor s en , especi a l ly if her work
( tone) will resist complete expiratio n , main taining the
involving cra n i over tebral flexi o n was maintained.
lower ribs in an elevated ( inspiration) position . Even tu
After such a pro tracted perio d o f recovery, i t was pos
ally. withou t correction, this
sible that the extreme o f left atl a n to - occipital j oint
will lead to a ' b arrel chest'
and the onset of 'apical ' breathing. It can a lso fa cilitate
l1exion may have remained hypersensitive permanently.
the developmen t of degenerative changes in the lower
However, her rate o f recovery, symptomatically a nd
cervical spine.
fu nctionaUy, since having the cause o f this seco n d a r y
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CLINICAL REASONING IN ACT ION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
dys fu nctio n corrected was rapid e n ou gh
to
i n cU ca t e
a i m wa s to ga i n a nd m a i n t a i n ra nge of motion of t h e
right j oint.
comp lete relief of sy m p to m s was l ikely. Amy's m a i n struggle was to avo id return i n g to he r habitual forward head pos tur e , a l thou gh her decision to take c h ar ge o f her ow n recovery by j oin i n g a gym demonstrated a determination not to return to her former painful l i festyle. ft was l ike l y that after such a p ro tr ac ted recovery time there would al w ays be some hypersen s i t ivity of the left atl anto-occ i p i t a l j o i n t ; however. short of fur ther trauma . it did not appear
that t h i s wo u ld continue to be
a
symp to mati c j Oint.
• Clinical reasoning commentary The c l i n icia n . an expert in manual therapy. has demonstrated the importance of t h in k i n g beyond
j u st the musc u loskelet a l syste m . The cUscussed po t enti a l in teractions between the musc u loskeletal and respiratory systems reflects
h ol ist i c approach
a
to treatmen t and management. Con sistent with this approach . t h e focus is not only on treating the pres
Did you consid e r treating the hype r m ob i l e l eft
ent primary i m p a i rme n t ( i . e . the
atlanto-occi pita l joint with a progra mme of
hypomobile
righ t
atlanto-occipital j oi n t ) . but also on t he preve ntion o f
m u s c l e sta b i l izati o n ?
p o ss i b le 'pathological s eq u el a e ' such ment of
• Clinician's answer
ba rrel
a
chest
as
the develop
and degenerat ive c h a n ges .
Mak in g a d eci sion about the progn os i s of
a
prob
M u scle stabi lization for t reatment of cervical sp i n e
l em is one of the m ost challenging tasks that
dysfu ncti o n is u nder take n if there is a n in d ication
manu a l t h e rap i s t faces . Pat ients i nevitably wish to
the
of se gm e n t a l i n st ab i l i ty o r obv i o us ( rath e r than
know whether full recovery is likely and. if so. the
assumed) we akness o f the cervical musculature tha t
rel ated timeframe and whether the problem will
cou ld predispose t o se gmental ins t ab i l i t y.
In th is case,
A my had a hy pe r mo b i l e j o i n t . that is an abnormal
rec u r. To
answer
t hese q u esti on s .
the
expert clini
cian usua l ly relies heav ily on the process of pattern
i ncrease in a n g u l ar ( p hysiological) motion, seco nd
recogn ition . which is based o n s u b s t a n t i a l experi
ary to a hypomobile j Oint in t h e same kinetic chai n .
ence
There were n o i n d ic a tio n s of s egmen tal i ns tabi l i ty i n
associated responses to intervention and p a th s to
with
similar clinical presen tations and their
either t h e cra n io ve rt ebra l j oints or i n th e midd le t o
recovery.
lower cervical s p i n e . Indeed. t h e an atomical i n te g rity
clearly aware that each p a t i e n t present ation is
o f al l structu res tes ted w a s i n tac t . The
tr e a tme n t goal
was
Nevertheless .
t h e cli nicia n in t h is
case
is
u n i q u e a nd any initi al prognostic hy po t h es i s must
to e l i minate
the
left
be tested by the appl ication of fi nd ings from the
a t l a n to-occipital j oin t ' s need to adapt for a loss of
inter view and phy si c a l ex amin ation .
motion wi th i n the k i netic c h ai n (i.e. mobilize the stiff
l i m in ary treatment. There is obvious evidence t h a t
right a t l a n to-occipi tal j o i n t ) . N oth i n g needed be d o n e
prognostic indicators.
to th e symptoma tic left j o i n t except for s o m e p al l ia ti ve
respon se
considerations ( e . g . avoida nce s tr a t egies ) . A m us cul ar
u n favourable (e.g. chronicity of the problem ) . h ave
re-education progra mme was in f a c t
initiated . but
its
to
both
m a n u al
as
well as pre
favou rable (e.g. good
therapy
treatment)
been considered and weighted in t he present
and
c a se .
• References D vorak , J. . Pe n n ing. L . . Haye k . j. et a t . ( 1 9 8 8 ) . F u nction a l d i a g n o st ics of t h e cervical s p i n e u s i n g computer tomo g r a p hy. Neurora d i ology. 30. 1 3 2- 1 3 7. Kapandj i . I . A . ( 1 9 74 ) . P hysi o logy o f t h e Joints. 2 nd e d n : Vo l . 3 . T r u n k and
Ve rtebra l Co l u mn . Ed i n b urgh: C h u rc h i ll Liv i n gst.one. Rothste i n . j.M. and S c a l z i t t i . D.A.
Wer n e . S . ( 1 9 5 8 ) . The pos s i b i l i t i es of
( 1 9 99 ).
Commen tary: physiotherapy q u o v a d i s . Advances i n Physiothe rapy.
9-1 2 .
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1.
moveme n t i n the c r a n i overte b r a l Acta Orth o p aed i ca Sca n d i n av ic a . 2 8 , 1 0 5-1 7 3 .
j o i n ts .
CHAPTER
16
A judge's fractured radius
with metal fixation following an accident Robert Pfund in collaboration with Freddy Kaltenborn
�
S U BJ E C T I V E EXA M I N AT I O N
RaIl' is a 54-year-old man who had fractured the distal part of his right radius in a motorcycle accident. No other signilkant injuries were sustained in the acci dent. He has been sent to our clinic for physiotherapy treatment 4 weeks after the injury. He has had an osteosynthetic procedure to stabilize the fracture with a permanent metal fIxation. after which he was placed in a half-cast for 3 weeks. The cast has now been removed. The accident did not involve another vehicle; rather. he was speeding and lost control. causing him to fall and slide off the roadway. There was not any significant damage to his motorbil(e and no involve ment [rom the insurance company. Ralf works as a judge. lives alone and has a person who looks after the household. He generally appears happy, even when talking about the accident. His general health is good, with only slightly elevated blood pressure over the last 5 years: this is well controlled by beta-blockers. Ralf appeared to be somewhat unl'it and volunteered that because of his work he had little time for exercise. He reported being about 10kg overweight and talked about doing some fitness training when he recovered. There was no past history of any upper limb prob lems, although Ralf had experienced minor neck and low back problems over the previous 10 years. He stated that these never lasted more than 2 to 3 days and would always settle spontaneously \vithout ever requiring treatment. The distal part of the forearm and the wrist was swollen. with the skin slightly shiny. His distal forearm hair in this area was notably very dark compared
with the other side. No redness was present in the injured area. At rest, Ralf described a feeling of swelling and slight soreness around his wrist. and increased sensi tivity on the volar side of his second and third finger extending up the middle third of the radial side of his forearm. He had no complaints of any other symp toms in the arms, neck, face or trunk. All his symp toms were approximately 30% worse in the morning when he woke up. and then improved as he moved his wrist and hand during the first hours of the day. For the rest of the d ay, these symptoms stayed in a mild form just above his level of awareness. He did not have any night pain and could sleep without difficulty. Walking with his arm hanging for more than 30 min utes increased the feeling of swelling and changed his perception of temperature in the whole forearm (felt colder than the other side). Standing \vith a depend ent arm did not produce the same symptoms, but he never stood for 30 minutes. When these sensations were present, the palmar side of his hand showed an increase in svveating that lasted for approximately 30 minutes after he stopped walking. While the dependent arm position produced changes in his feel ings of swelling. temperature and sweating, it had no affect on his wrist soreness. Using his hand during eating and any writing (he was right handed) immediately increased his resting symptoms around 10%, whereas more specil'ic move ments of his wrist produced a sharp pain (4-5110 on a visual analogue scale), which eased immediately
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229
CLI N I CAL REAS O N I NG I N ACT I O N: CASE STU D I ES FROM EXPERT MANUAL TH E R A P I S TS
when the wrist was taken out of these positions . Ralf's
the inlluence of movements or fixed positions of the
main concern was his restricted and painful movement,
neck, thorax or shoulder complex showed no relation to
especially the combined movement into dorsaillexion
RaWs symptoms other than the effect of the dependent
and radial abduction. Other screening questions about
arm position aLready described.
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY
o
What were your initial impressions at this stage!
particular, care was needed not to produce too much pain and to avoid making statements about possible
• Cli n i cians' answe r
impairments/disability, or any other comment that
The fracture was only of the radius with
no
involve
ment of the wrist jOint or the distal radioulnar jOint.
could increase his fear and uncertainty about
the
injury and his prognosis.
Therefore we would not expect too much di[(1culty in restoring movement. Because of the time since the injury (4 weeks), we would take care in applying stress
II
Could you comment on what potential sources you felt were implicated by his different symptoms!
by active or passive manoeuvres directly to the stabil ized radius. At this stage, his psychosocial status did not appear to be an issue (for example, there was no
• Cl i n icians' answe r
fear of losing his job), and he seemed to be coping well
Disturbance of the autonomic nervous system could be
with his injury. His general health and fitness were
the source of the:
not ideal, but these were not considered su[(1ciently compromised to affect significantly the healing of his injury. Overall, Ralf seemed to have a straightforward presentation with slight autonomic nervous system disturbance. We would place him into the normal range of patients with a fractured radius.
• swelling of the distal part of the forearm and wrist • shiny skin • darker forearm hair • swelling and slight soreness around his wrist at rest • increased sensitivity on the fingers and radial side of his forearm
D
How did you interpret the specific nature of
• feelings of swelling, temperature perception and
the increased sensitivity he reported! Similarly,
sweating in the arm if it was dependent for more
what were your thoughts at this stage regarding
than 30 minutes while waLking.
the changes in swelling, temperature and sweating that he had noted when he was walking with his arm dependent! Did his report of these symptoms and symptom behaviour elicit any plans on your part for specific phYSical assessments!
The continued presence of inflammation couLd cause the more severe symptoms to occur in the morning on awakening with improvement on movement of the wrist and hand, and continued mild symptoms through the rest of the day. Irritation of the median and the
radial nerves in the
wrist area could cause the feeling of swelling and
• Clinic i ans' answe r
slight soreness around his wrist at rest and increased
In patients with stabilized fractures, we commonly see
sensitivity on the fingers and radial side of his fore
symptoms suggestive of slight autonomic nervous
arm. Altered sensitivity of the central nervous system
system disturbance. These alterations mostly disap
could also give rise to these symptoms.
removed.
Damage to the radiocarpal or intercarpal (radial and
Therefore, we would not use any specific assessment
central column) joints could give rise to the restricted
pear
when
the
stabilizing
material is
techniques at this stage but would take care not to
and painful movement, especially the combined move
raise his level of sympathetic activity any further. In
ment into dorsal flexion and radial abduction.
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16 A J UDGE'S FRACTURED R ADIUS WITH METAL FIXATION FOLLOWING AN ACCIDENT
possible sources and tissue mechanisms is obvious. the
• Clinical reasoning commentary The clinicians'
through their
breadth of
answers
reasoning is ev i de n t
here. Reference is made to
considerations r e g a r d i ng the patient's psychosocial
status. po te n tial sources of the sy m pt oms . pain mechanisms. tissue mechanisms. precautions and prognosis. Clearly. reasoning is t a k in g place on m ul tiple levels. While diagnostic reasoning with respe c t to
tEl
recognition that care is needed for the patient's under s t and ing and feelings re ga rding the
injury and prog
nosis also illustrates a broader consideration for the patient's psychosocial status
a nd
how
this
can in.llu
ence the patient's symptoms. This sensitivity to the patient's 'pain experience' is a nice example of what was discussed as 'narrative reasoning' in Chapter 1.
PHYSICAL EXAMINATION to
• Screening examination The screening examination was used to identify the area where it is possible to influence the patient's symptoms by alleviation and
provocation. Based on
these Ilndings. the next more detailed part of the phys ical examination can be planned (Kaltenborn, 1999). Using the painful combination of movement into dorsal flexion and radial abduction. differentiation of
a
sharp, more deeply located pain in the same a re a .
Supination of the forearm was grossly restricted and painful in the radial and volar aspect of the wrist. Pronation was also restricted, but less so than supin ation, an d elicited only
a
slight pain. When tested
passively and compared with his active movements, each movement had slightly more available range but increased pain.
regional involvement between the wrist/hand com
Translatory (passive accessory)
plex. the elbow complex and neural structures was
movements
performed. To provoke the symptoms. Ralf's wrist was positioned just short of the onset of pain (PI). Ralf was then asked separately to move the elbow jOint
(flexion and extension). the shoulder girdle (elevation and depr essi on ) and the cervical spine (side bending left and right. flexion and extension) to determine if any of these movements provoked his symptoms. For the alleviation differentiation. Ralf's wrist was positioned in the same combined movement pOSition. only this
Translatory 'joint play' movements (i.e. traction, com pression an d gliding), assessing range and quality of
movement. were p erfor med in the resting position and then again just short of end-range (Kaltenborn, 1999). These tests are used to assess the arthrokinematics of the wrist complex and not the pain response.
Distal radioulnar joint. PaSSively gliding the radius in a dorsal a nd volar direction showed slightly more
time just into pain, and the same movements of the
resistance than was seen on the other side. When
elbow, shoulder girdle and cervical spine were used.
pre-positioned j ust short of end-range. there was
None of the provocation differentiation manoeuvres
restricted dorsal gliding of the radius in supination,
elicited his symptoms and none of the alleviation
and restricted volar gliding in pronation. The resist
manoeuvres eased them (Pfund and Z a h n d,
2001).
ance began very early in the range in both supin ation and pronation, although the pronation end-feel
• Detailed examination
was harder co mpared with the other side.
Wrist joint.
Angular (physiological) movements (active and passive) of th e wrist Active movement
of Ra lf
General translatory movements (i.e.
traction and gliding in volar. dorsal, radial and ulnar directions) of the whole r ig ht wrist complex
s hand into dorsal Ilexion
in the resting position showed less range and more
produced a sharp pa in deep in the dorsal aspect of his
resistance in eacb direction com pared with the left
'
mo re super
wrist . Pre-positioned ( s h ort of end-range) traction
ficial pulling over the dorsal part of the wrist joint.
into more resistance, in volar flexion and ulnar
Ulnar abduction gave him a superficial puillng on the
abduction, produced the same superficial pulling
radial side of the jOint; whereas radial abduction led
as described during the angular movements.
wrist jOi nt ; whereas volar nexion gave
a
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CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
Volar gliding of
In te rcarpal joints.
scaphoid on
radius and of lunate on radius was restricted. The
(external rotation while the radius was stabilized) alleviated the pain.
other intercarpal joints showed no movement alter ations. Movement of lunate on radius was most
Differentiation intra- versus extra-articular
restricted when the wrist was positioned in pure
components
dorsal flexion;
the movement of
scaphoid on
radius was most restricted when the wrist was pre positioned in combined dorsal flexion and radial abduction (compared with the other side).
With the wrist pre-positioned into combined dorsallJex ion and radial abduction just into pain, general traction and compreSSion between the forearm and the carpus was applied. Traction immediately decreased the pain, whereas compression increased the pain.
Isometric contraction Because of the history, the results of the regional dif
Differentiation of intracarpal components
ferentiation (i.e. moving the neck, shoulder and elbow
Provocation of
with the wrist pre-positioned before and after PI) and
abduction.
the quality of the passive movements of the wrist
short of pain, the radial and central columns of the
pain in
dorsal flexion
and radial
With the V\rrist pre-positioned
just
(firmer end-feel compared with the other side), no iso
carpal complex
metric contraction tests were applied at this stage.
column was tested by stabilizing the radius and
Specific provocation and alleviation tests
movement of both trapezii (os trapezium
were differentiated.
The radial
moving the scaphoid in a volar direction, followed by
Additional provocation and alleviation differentiation tests are applied to gain more specific information about the area where the symptoms seem to be pro voked. Through this testing, we try to answer the following questions:
distal radioulnar jOint or the intercarpal joints, is the likely source of the patient's symptoms? • which movement in the symptomatic jOint provokes • what is the dominant provoking component (intra versus extra-articular) of the painful movement?
umn, the lunate was moved against the stabilized radius in a volar direction, followed by a volar move ment of the capitatum against the stabilized lunate. radius in a volar direction reproduced Ralf's pain. None of the other movements produced any paln. Alleviation oj pain in dorsal flexion and radial abduc tion.
With the wrist pre-positioned just into pain,
were differentiated for pain relief. Based on a bio mechanical rationale, the radial column was again tested by stabilizing the radius and moving the
Differentiation of distal radioulnar joint
scaphoid, this time
versus intercarpal joints
in a dorsal direction. Next, both
trapezii were moved in a volar direction while the With the fore
arm pre-positioned just short of pain, the radius was first moved into the volar and then into the dorsal direction while the ulna and the carpus were stabil ized. Movement of the radius did not provoke any pain, whereas movement of the whole carpus into more supination (internal rotation while the radius was stabilized) reproduced Ralf's typical pain.
Alleviation of pa in in supination.
scaphoid was stabilized. In testing the central col
the radial and central col umn s of the carpal complex
the patient's symptoms?
pain in supination.
and os
in a dorsal direction while the
Of all these tests. only movement of the scaphoid on
• which joint out of a complex of joints, sLlch as the
Provocation of
trapezoideum)
With the forearm
pre-positioned just into pain, the radius was moved into the volar and then the dorsal direction while the ulna and the carpus were stabilized. Movement
scaphoid was stabilized. In testing the central col umn, the lunatum was moved against the stabilized radius in the dorsal direction, followed by a dorsal movement of the capita tum against the stabilized lunatum. Of all these tests, only the movement of the scaphoid on radius in a dorsal direction alleviated Ralf's pain. while none of the other movements inlluenced the pain (Pfund and Zahnd.
2001).
Examination of ad j acent j oints and structures Translatory testing of the
Proximal radioulnar joint.
of the radius did not ease the pain, whereas move
prm.imal radioulnar joint showed a decreased gliding
ment of the whole carpus into more pronation
of the radius on ulna in
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eill
anterior direction.
16 A J U D G E'S F RACTU RED RADIUS WITH M ETAL F I XAT I O N F OLLOWING AN ACCIDENT
Muscles of tile forearm.
Volar flexion of the wrist
with fmgers two to live fully Oexed. and dorsal Oexion of the
ist with these lingers fully extended were
'wr
both restricted comp ared with the left side. With all lin gers Oexed, there was also less range in ulnar abduction, whereas racUal abdu ction was the same as the u ninvolved side. There was a IIrm elastic end feel in each positio n. Spinal assessment. Based on the neu rolog ical rela tionship of the cervical (C4-T1) and t hor acic
(T4-T8 s ympat hetic
origin to upper ex tremity) wrist joint complex. spinal palpation was applied in prone lyin g to get a general idea about tissue texture a b normal i ties. Slight a l ter a t ions of the soft ti ssu e on the right side bet w een C5 and C7. and sti f fness and soft tissue changes between T5 and T8, were presen t. All chan ges were classified as minor tissue alterations from the si tua tion on tbe other side. spines to the
REASONING DISCUSSION AND CLINICAL REASONING COMMENTA RY
o
What was your hypothesis at this point regarding the dominant pain mechanism?
At this stage,
pain mechanisms (in or d er ) considered most likely contri bu tin g to thi s pa t ient 's symptoms and disabi l ity were:
The
com plex
somatic tissues ) 2. autonomic n ervous s yst em 3. cen tral
the primary potential source we hypothe move ment impairment of the w rist j oin t a nd the functional ly connected structures. suc b as the muscles of the fo rearm, res ul tin g from the fracture and the peri o d of immobilizat ion ( hypothesis 1). Lack of mobility between the lunate and scaphoid on radius seemed to be the dominant cause of the restricted dorsal and volar flexion (hypothesis 2). Movemen t alterations of the racUus on ulna in the distal racUoulnar jOint were lU<ely responsible for the re striction in pronat ion and supination (hypothes is 3). The do minan t contribut ing factor was conside re d to be a disturban c e of the autonomic nervous system, the symptoms of which ap peared to be neurophysiologically altering the se nsi tivity threshold of the local 'wrist structures (hyp othe sis 4). There were no n egating features evident so far to diff eren t iate these four h ypotheses . sized was a
• C l i n i c i an s ' answe r
1. p eripheral nociceptive (i.e. local wrist
• Clinicians' answer
nervous system
4. pe r ip heral ne urogenic. Tbis order is proposed because of the direct trauma in the history. the len g th of the history and the cl i n ical
presentation. Present k nowledge re garcUng pain mech anisms suggests that witb trauma there is inc reased likelihood of p a thobiological changes in the perip heral and cen tral nervous systems. While central mechan isms were not strongly su p por ted at this stage of our reasonin g . tbey still must be considered. From the c lin ic ians' clinical experiences, peri pher a l neurogenic mechanisms are often involved in p atie nts with metal llxation at the w r ist . likely caused by an irri t a tion of local peripheral neur al tissue (e.g. median nerve in the c a rpal tu nnel ) .
• Clinical reas oning commentary Two characteristics of expert reas oning
evident in the clinical examination and the author s ' answers is their use of differentiating procedures and their consideration of several poten tial sources operat ing Simultaneously. Kleinmuntz (1908) in t rod uce d the concept of 'maximizing principles' to describe the
II
clinical procedures and associated reason i n g
Please comment on the hypotheses regarding
that ex perts use in order t o narrow down compet
potential sources and contributing factors
ing hypo t heses efficiently. The clinicians
that you were considering by the end of your
cific provoking and alleviating tests in this patient's
of spe
example of principle ' to enhance the efficiency and accuracy of the ir examination.
physical examination. Include the supporting
physical examination represent a clear
evidence, and also any negating eVidence,
a 'maximizing
from your examination for your hypotheses.
use
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CL I N I CA L REASO N I N G I N ACT I O N: C A S E STU D I ES FROM EXPE RT M A N UAL T H E RAPI STS
Proliferation
Fig. 1 6. 1
Diagram of normal time for regu l ar tissue h ealing. (Repro d uced with kind pe rmiss ion ofT h ieme, from
van den Be rg, 1999.)
Reassessment of the physical findings from the ini tial session revealed no change. The plan for the sec At the end of the initial session, the normal healing time after
a
fracture and the different stages of heal
ing and their ability for loading was explained to Ralf. The model described in van den Berg (1999) was used as it provides a useful overview about the healing time and the ability of loading injured tissue with movement (Fig. 16.1). Because of the 3-week period of immobil ization in the cast,
a
self-exercise programme was insti
ond session was to find techniques to increase further the range of motion
(ROM) of the wrist joint, particu
larly dorsal llexion, with the aim 01' progressing into more resistance. Because of the metal fixation of the radius and the unknown ability of the fixation to withstand
mechanical
force,
traction
techniques
were used initially to minimize the stress on the radius.
tuted. Ralf was instructed in regular pain-free and resistance-free movement into dorsal llexion and volar Ilexion, radial abduction and ulnar abduction, and pronation and supination, to be performed every hour
Treatment techniques Translatory traction into resistance (i.e. end of grade
[o ' r
II: Kaltenborn, 1999),
ment he should use, resistance-free movement was
the forearm stabilized. This was carried out with the
was
applied to the carpus with
wrist in the resting position and then submaxirnally
demonstrated on his left wrist.
pre-positioned into dorsal flexion (Fig. 16.2), radial
• Second
abduction, volar flexion, and then ulnar abduction
visit
(Kaltenborn, 1999). Retesting was applied after mobi
Two days after the initial session, Ralf returned for his next treatment and reported that his hand 'feels much better' and that the swelling and soreness had decreased around 15-20% compared with the initial session. When asked to demonstrate the self-exercises, he
lizing (10 times for 10 seconds) in each position, with increases of the
ROM in all directions. The same pro
cedure was repeated and the result was similar. with further increase of
ROM and a more comfortable feel
ing when moving his band.
showed them correctly and appeared to have no fear moving his hand in the demonstrated range. No addi tional symptoms had developed since his first session.
Self-exe rcise
The sharp pain in dorsaillexion and radial abduction
Based on these results. Ralf was instructed in how to
was unchanged.
use a similar technique as part of his self-exercise
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1 6 A J U D G E'S F R A CTU R E D RA D I U S W I T H M ETAL F I X ATION FOLLOWING AN AC C I DE N T
• Third
visit
Two days after the second session. Ralf returned with further improvement in his ROM (both pbysical I1nd ings and patient's comments), but with less gain in the swelling or the soreness. While there had been no additional symptoms. the sharp pain in dorsal l1exion and radial abduction was unchanged. He was able to demonstrate his initial session and his second session self-exercises well. Fig. 1 6. 2
Tran s lato ry t raction i n t o resi stance applied
to the carpus with the forearm stab i l ized (th e rapeutic technique).
The plan for the third session was first to increase the range of movement and reduce the pain produced dur ing dorsal Ilexion and radial abduction. Initially. the translatory traction used in the previous session would be progressed and then, if this were unsuccessful, spe cific mobilizations of the intercarpal bones would be tri aledo After that, the plan was to test the inlluence of the shortened muscles on Ralf's movement impairment.
Treatm ent techniques Distraction of the carpus on the stabilized forearm, pre-positioned in four submaximal positions (dorsal flexion, volar l1exion. radial abduction and ulnar abduc tion), was applied into more resistance (first to the end of grade II; Kaltenborn, 1999). then just into grade ill ('just over the slack'; Kaltenborn, 1999). Retesting
was performed after mobilizing (10 times for 10 sec onds) in each position and showed a proportional increase of the ROM in all directions, as measured by simple observation of the movement. The same pro cedure was repeated, resulting in further increases in the ROM and a more comfortable feeling for Ralf when moving his hand. The specific provocation and allevi ation tests were unchanged from the initial visit. Even without specific treatment to the distal radioulnar Fig. 16.3
Trans latory traction into resistan c e app lied to
the carpus with the forea rm stabil ized (self-exe rcise).
joint, the supination movement improved (range and pain), whereas pronation was unchanged (i.e. restricted but no pain).
programme. Specifically, he was shown how to pre
Stretching of the extensor and flexor muscles of
position his hand. stabilize this position and apply
the wrist into slight resistance was trialed next. The
traction at the wrist joint (Pfund and Zahnd. 2001).
finger joints. the wrist joint and joints of the forearm
He was advised to perform the self-traction exercise
were pre-positioned in their pain-free range and the
into resistance (end of grade II; KaJtenborn, 1999),
stretch (five times 15 seconds) was applied by mov
in the same positions as the therapeutic technique
ing the elbow into extension (Evjenth and Hamberg.
(10 times for 10 seconds) every 2 hours (Fig. 16.3). He was also advised to perform his angular selJ
1984). Pulling in the stretched muscles was felt, and not the speCific pain in his wrist, during this procedure.
exercises every hour. moving the hand without pain
Retesting after stretching each position showed
or resistance into dorsalilexion. volar Ilexion, radial
slight increase in the ROM and a subjective improve
abduction and ulnar abduction for a total of 5 minutes.
ment in the quality (ease) of moving the wrist.
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a
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
Based on these results Rail' was taught how to use .
a similar m uscle stretchin g tech niq ue as a self-exercise -
for the extensor and flexor muscles of the lNrist (Evjenth and Hamberg. 1991). He was a lso shown how to apply self-tra ction in the pre-posi tioned hand in order to mobilize the wrist into m or e resis tan ce
.
The se l f-exercises to be performed at th i s stage were : • every hour, moving the hand wi.thou t pain or resist
an ce into dorsal t1exion. volar Ilexion, radial abduc
5 minutes 2 hours . self-traction into resistance (i.e. just
tio n and ulnar abd uc ti on for a total of • every
into grad e III; K altenb or n 1999) in the same pos ,
itions as the therapeu t i c te c hnique (10 t i mes [or 10 seconds)
Fig. 16.4
Translatory gliding of the scaphOid against the
radius (therapeutic technique).
• stretc hing of the flexor and ex ten s or muscles of the wrist joint into slight resistance four times a day, each muscle group five times for 15 seconds.
• Fourth
visit
Three d ays later. the ra nge of m ovement into volar flex i o n and ul n ar abduction was much better. while o n ly sli gh t improvement was ma de into dorsaillexion and radial abduction. Despite the increase in ROM. the sharp pain at end of r ange was s til l un c han ged Supin .
ation and pron a tion ROM showed only a slight improve ment: h o wever the pain w ith supination was reduced ,
a pprox ima tely 50%. while pronation was nearly p ain free. T h e 'autonomic' symptoms were u n c h anged The .
specific provocation a n d a l l e v i ation tests showed the same pattern as at the initial assessment. Reassessment
improvement in ran ge a n d with
of musc le length revealed
response but still a n altered end-feel c ompared the other side
.
The plan for thi s treatme n t was to find techniques that were able to change the sharp pain in
tion te c hn iq ues for the restricted radio c arpal j o i n ts .
against the radius in the volar d irectio n was continued
of the s ca ph o i d a gai nst the III (Kaltenborn.1999) ( five times. 10 seconds; F ig 16.4). Retes ting sh owed a direct reduc tion of the shar p p ai n
Trans l a to r y volar gliding
rad ius w a s ap plied just to the beg i n nin g of gr ade .
a
the shar p pain and n o improvement in the ROM. Based on these re assessments. mobiliza tion of the scaph oid in this session.
Treatment techniques
a nd
Translatory gliding of the scaphOid against the
dorsal t1exion
and radial abduction. To achieve this. speci fic mobiliza were tri a led
Fig. 16.5
radius (self-exercise).
s l i g ht improveme n t in the ROM into dorsal flex
Self-exercise In addition to the existi n g progranlme, Rail' was t a ugh t to a p ply a speci fic m obili za tion te c hn i que for the sc a p h oid aga inst the radius (Fig. 16.5). to be per
ion and radial abdu c tion Transl a tory volar glid in g
formed every 2 h ours (5-10 times for 10
of the lun a t u m a gainst the radius was applied just to
The other self-exercises were unchanged. except he
.
seconds).
the beginning of grade III (five times, 10 seco nds)
w a s instructed to take the muscle stretches into more
(Ka lten born. 1999). Retesting showed no reduction o f
resistance.
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16 A J U DG E ' S F RACTU R E D RA D I U S W I T H M ETA L F I XAT I O N F O L L OW I N G AN ACCI D E N T
� J . D
R EASO N I N G D I S C U S S I O N A N D C L I N I CA L REASO N I N G C O M M E N TA RY
Clearly you see patient understanding of tissue
The
tionally connected struct u res (hypothesis 1 ) .
the key features of the van den Berg ( 1 999) model
increa se of ROM throug h local stretc hing techn iq ues
of tissue healing and how you incorporate this
of th e wrist j oint and the forearm muscles supported
into your management and prognostic decisions ?
• C l i n i c i a n s ' a n swer d i agram for the normal time o f regu l ar tissue heal ing ( F i g . 1 6 . 1 ; van den Berg, 1 9 9 9 ) is clinically very use ful in expl a ining to patients the different stages of heetling. From a knowledge of these different stages , we
mcillu al therapy treatment. In the inflammation phase (days 0 to 5 ) , a frag ile situa can apply and progress our
tion is domin ant. New b lood vessels are being buil t and
presentation is mostly irritable ( L e . pa in is easily a g g ravated a nd does not settle quic kly) . Therefore, dur in g this stage of heal ing our p assive and active treat ments are ap p lied without provoking pain a nd withou t going into resistance. In the proliferation phase (d ay s 6 to 2 1 ) , only 2 0 % of the n ormal loading ability of the inj ured tissue is restored (McGonigle and M a tl ey, 1 9 94) and . t herefore, our active and pa ssive movement is applied only to the beginin g of resistance and/or to the onset of pain . In th e remodulation phase (after day 2 1 ) , our treatment tech niques will typica lly b e taken more and more into resistance. gradually being pr og ressed based on our ongoing reassessment . This model is purely locus sed on tissue heaJing and should not be a p pli ed without consideration of the different p ain mechanisms th e
and altered healing capacities . s uch as in a systemic d is ease (e.g. rheuma toid arthriti s ) . While being broadly guided by this model, our treatment progression is still largely informed by our continuous reassessment. How did the reassessments and the patient's progress up to the fourth visit support, or not support, your previous hypotheses regarding the dominant pain mechanism, potential sources and contr i buting factors ?
• Clinicians' a n swer There was no ch an ge in our hypotheses regarding pain mec ha n is m s , exce p t perhaps cen tral and perip hera l ne u roge n ic pa t ho l og ic al mec h a n isms were less likely ; our evolvi ng thoughts regarding sources and contribut in g fac tors were as follows.
this hypothesis . Lad, of m o b i lity bet wee n 1 lll1ate and scaphoid
011
radi us as the do m in a n t cause of the re stricted
The
II
Movement dysfu n ction of the wrist joint and fll nc
h ealing as important. Would you bri efly highlight
do rsal and vo lar flexion (hypoth esis
2).
This
hy po t h es i s was n o t proven t h rou gh speci fic tre a t m e n t tec h n iq ues at t h i s stage. Move ment alteratiol l s of the radi us on ulna in the distal ra diou lnar joint being responsible fo r the restriction i n p ronation and supination (hypoth esis 3 ) .
This hy pothesis was not proven through
specific treatment techniq u es at this stage. A utonomic nervo u s system distu rbance (hypoth e s i s 4) . The red uction in swel l ing and soreness c o u l d b e i n terpre ted as de c re ased d isturbance o f t h e auton omic ner vo u s syste m . L o s s o f fear abou t movement, a better
un de r s ta n d i n g of the w h o l e b l ood s u pply thro u g h regular p a i n - free movement r ep resented a d d i t i o n a l fac tors th a t h a d i mprove d a n d wh i c h may have b een con trib u ti ng t o his s y m p tom pres en tation in their own righ t or as a ma n i fest a t i o n o f h i s a u to n o m i c d is tu rb a n ce . ' process o f h e a l i n g ' . and a n i mproved
• Clinical reas on i n g commentary The clinicians' treatment selection and progression in this case are based o n a balance of biomedical (propositional ) an d clinical or craft (non-proposi tional) kn owled ge . While the biomedical pri nc i p les of tissue hea ling will generally dict ate similar treat ment guidelines as the clinical presentation wou ld suggest (such as avoiding much force in both the inflammatory stage and "vith an irrit able p resen ta tion) . the clinici.ms' flexibil ity in th ese jud gments is evident. by their caution t hat the ab ove model must be considered within the broader picture of pain mechanisms and the patient's healing capacity. Biomedical pri nciples cl e arly prov ide an initial fnunework within whic h management decisions are made, but the variability of presentations within this framework necessitates the l1exibility of th inking shown here. That i s . even within th is biomedical
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C L I N I C A L R E A S O N I N G I N ACT I O N : CAS E S T U D I ES F RO M E X P E RT M A N UAL T H E RA P I STS
model. treatment hypot h e ses are contin u a l ly re - eval u
thoughts h a ve evolved w i t h each visit and assess
ated on the basis of o n go i n g cli nical reassessment.
men t . wit h some hy poth eses supported
clinicians' reaso n i n g has been g u ided by the ongoi n g reassessment. which resulted i n further. deeper u nderst a n d i n g of the patie n t ' s presentatio n . N o t bei n g l o c ke d i n to their initi a l hy potheses . their The
.
were
while others
not. Treatment is clea rly not the end of the
decisio n-maki n g
process.
Rath er.
toge t her with reassessment represent
t reatment a
fo rm of
hypot hesi s testing.
o n ly s l i g h tly u p to the seve n th v i s i t a n d then was
- .
u n c h a n ged . A fte r the s i x t h visi l . Rail' was i n troduced M a n agemen t contin ued over a fu r t her five v i s its ( v isits
to the seq uence tra i n ing system ( C u n nari e t al . . 1 9 8 4)
5 - 1 0 ) . The total ROM ava i l able a t the wrist j O i n t a t the
with the aims o f i m pro v i n g general fitness a nd relearn
begi n n i n g of this stage (visit 5 ) was nearly u nc hanged
ing to use the inj u re d h a n d ( F i g .
fro m the prev ious session. but the s h arp pain prod uced
that none of the exercises duri ng the seq uence training
by d o r s a l nexion and radial abd uction was reduced
was per fo r med w i t h i n the p a i nful ROM o f the wrist.
1 6 . 6 ) . C a re was taken
ap prox i m a tely 3 0% . RaWs demonstration o f the self
At this stage. the temperature c h a n ges and the swel ling
exerc ises was correct and no addi tion a l symptoms h a d
of the h a nd b f the dependent arm when wa l king
developed s i n c e the last ses s i o n .
s h owed o nly s l i g h t change.
D u r i ng the n e x t sess i o n s . r a d iocarpal mo b i l iz a t ion
was c o n t i n ued . As the r a n ge i n creased . mobiliz a t i o n o f t h e l u natum again s t
the rad i u s . i n a vo l ar d irecti on
In addition to h i s h a nds-on treatme n t . Ra i l' tra i ned
fo ur times a week fo r approx ima tely 45
m i nu
t es with
low resistance. The feel i ngs o f swe l l i n g and s l i g h t sore
parti c u l a r ly. reduced the s h a rp pain fe l t with the com
ness a r o u n d his wrist j o i nt. and the hyperaesthesia on
b i ned movement of dorsal nexion and rad i a l abduc
the volar side of his second and t h i rd fi ngers and the
t i o n . The restricted a n d pai nfu l s u p i n at i o n move m e n t
middle third of the rad i al side of his fo rear m . decre ased
i m proved m o s t with mobil izati o n of the prox i m a l a nd
steadily and after the tenth visit o n ly mi nor sensations
d istal rad i o u lnar j Oints . whereas p ro n a ti o n i m p roved
rema ined . S i nce he had s t a r ted to do the seq uence
(a) Fig. 1 6. 6
(b) Exa m p l e of s e q u e n c e tra i n i ng to i m p rove general fi tness a n d re learn use of the i n j u red h a n d .
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1 6 A J U D G E' S FRACT U R E D RA D I U S W I T H M ETA L F I XAT I O N F O L L OWI N G AN AC C I D E N T
traini n g . t h e s we l l i ng h ad lessened . a n d after h e had done h i s daily ' worko u t ' h i s hand fel t n e a r ly n o r m a l A lso the feel i n g of a l te red temperature i n t he wh ole forea rm of the dependent arm d u ri n g walki n g w as .
� I} -
nearly red uced by 100%. He described the o ve r a ll dy sfu n c tion of h i s right arm to be a pprox im at e ly 2 0% compa red wi th the other sid e .
REASO N I N G D I S C U S S I O N A N D C L I N I CA L REASO N I N G C O M M E N TA RY
C o u l d yo u e x p l a i n you r reas o n i ng fo r i n trod u c i ng the s e q u e n c e tra i n i ng at th i s stag e , h i g h l ighting the parti c u l a r features of h i s
d o in g u ncontrolled movements i s low, because of the stabilized position o f the p atien t s body in s i de the sequence training mach i ne. '
p re s e n tati o n a n d re s p o n s e to treatm ent that p rom pted i ts i n c l u s i o n h e re ?
• C linicians' answer
• Clinical reaso ning commentary
It i s o u r c l i n i cal ex perience that patients with postsur gical pro blems, such as Ralf. achieve better re su lt s if i m p r o vemen t of ge ner a l fitness and the integration of the invo lved body part ( here the wrist) into to t a l b o d y movemen ts is initiated than i f local manoeuv res alone are used (e. g. mobi lization ) . After the sixth t reatment with passive and active movem e n t . as well as sel f-exercise, we fel t we had s u fficient i n formation regarding Ralf's attitude toward exercise and the abil ity of the inj u red tissue to toler a te mecha n i c a l l o a d . The presentation seemed to be n on i rr i t a b le and Ra l f was a b le to demonstrate t he selected exercise protocol cor rectly without fear o f using the hand. The sequence training sys tem is easy to teach a n d t he potential for
The bread t h of the cl i n ici a n s reasoning to inc l ude consideration of th e patient's broader health/fitness s ta tu s in its own right and wi t h respect to h ow it
-
BS·'.!§Hi" " rf'rfB§;.t§·'_ At this stage. Ralf con tin ued Ws regular sequence train ing and also received two treatment sessio ns per week for the next 2 weeks. mobU izin g the hypomobUe struc tures. Ral! res umed work 6 weeks a fter the inj ury, at wWch time treatment was reduced to on ly o nce a week . In adcUtion to h is normal work routine. he had to c a tc h up with all the files he had not worked on during the la st 6 weeks. neceSSitating a red uc tio n in h i s tra in in g to two or three times a week Then 2 weeks after starting work . he s topped the tTaining completely Following this. he started to get more soreness around the whole wrist j oint and the swe lling . mornin g s tiffness and p ain all i ncreased ; h oweve r, the temperature c h a n ge and swell i n g feelings during walking di d not return . .
.
'
may be contributing to the p atient s current symp toms is a gain evident in this answer. Reflection is t he means by w h i ch clinical patterns are d i scovered and cl inic ally val idated. Wh ile the c l i n ici a n s reflective expe ri ence has led them to incorporate their sequence tra ining into the programme of such patients, the programme itself is n o t a set protocol or recipe. Rather, based on their consideration of the pa tie nt s understa nding/attitude. as well as his spe cifi c p hys ical presen tation, they determ i ned when best to commence his t r a i n i n g and a t wh at level. '
'
'
Because of h i s busy schedu le. Rai l' was u n able t o attend more than one treatment session per week a n d had lo s t his m otiva tion for the sel f-exercise. He was in c reasingly fru strated with hi s diJficul ty getting caught u p with his backlog o f work and his lack of time a n d energy fo r h i s exerc i s e s . H e t h o u g h t he wo u l d never be the s a me person he was befo re. The p a i n in his hand was worse i n th e even i ng but settled when he relaxed at home watc h i n g TV o r l i s tened to music. No additional symptoms had appeared . W h i l e local treat ment tec hniques (mob i l ization and st retchin g ) co u l d c h a nge the range and the pain response of the restricted movements . the improvement was o n ly retained for 1 to 2 hours. A l s o , mobi lization tech n iques a ppl ied to the cervic a l and the tho racic spines a l tered the sensi ti vity s t a te of the hand for a short period of time. but t h i s i mp rovement d i d not last.
Copyrighted Material
. I
C LINI CAL REASONING IN ACTI ON: CASE STUDIES FROM EXPERT MANUA L THERAPISTS
S ix weeks after he started work. he described the
exercise h a d he lped him q u i te a l o t . Because of the
overa l l dysfunction of the r i gh t arm to be more than
movement restrictions t h a t still remained. an ad d
40% . Ag ree i n g that manual tec h n iques alone were not
itional two treatme n ts per week were recommenced .
i mprov in g his s i t u a tion . and since he felt he had no
Fo u r weeks later, the mor n i n g sti ffness a nd s we l l i n g
time to d o regular exerc ises because of h i s busy work
were absent, a nd dorsai llexion a n d rad i a l abduction
schedule. we decided to s top treatment for the next
s h owed o n l y slight res trict io n and m ino r dis comfort
6 weeks. R a lJ was advised to perform his normal activity
at e n d- ra nge S u p i n a t i o n was now norma l , a l though
and resume the self-exercises at least once a d ay
the range of pro n at i on was still u nch an ged . with end
.
.
Ra l f c a me b a c k i nto o u r c l i n ic 8 weeks l a ter with
range pa i n perSisting. At this poin t . h and s - o n tr e a t m en t
nearly all sym ptoms red uced about 60%. There was still
wa s s to p ped a n d it was ag reed that he wo u ld continue
some morn ing stiffness and slight swe l l i n g , bu t h e d id
with hi s sequence tra i n i n g t h ree t i m es per week. Ten
after the acci d e n t . the m eta l fix a t i o n was
not see t h is as abnorm a l . R a W s wri st wa s s t i l l sl ig h tl y
months
restricted i n to dorsai llexi o n and radial a bd uc t i o n b u t
removed . Ten days after the surgery, he des c r i bed prona
.
on ly m i n or p a i n was fel t when h i s movements were
t ion as be i n g much better tha n befor e the fLx ation was
ta ke n to end-ra n ge. Pronation was t he s a m e a s at t h e
removed . Rail' res ume d his seq u e n ce tra i n i n g a week
l a s t v i s i t , whereas t h e supination range w a s i n c reased ,
a fter s urgery and th e wrist a n d fo r earm were again
w i th o n ly minor restriction a n d no res i d u a l pa in
mob ilized bec a u se of t he restricti ons in dorsa i ll ex ion
.
,
Excep t for the r estr i cted pro n a t i o n , Ralf was a b l e to
ra d i a l abd u c t i o n a n d p rona tion that stU! remained .
move his h a n d p a i n-free w i th a ll h i s d a i ly activ i ties .
After six tre a tme n ts the wrist mo ve me nt was pain-free
He h a d do n e his muscle stretch i n g a n d s e l f-traction
and without restriction com pared w i th the ot her side.
.
tec hniques every eve n i n g for the p a s t 4 weeks. He
Pronation and sup i nation were without pain , but
seemed to be much more relaxed and did n o t mention
pronation still lacked 1 0 degrees of range. The mobiliza
h is wo rk at all. Whe n he was as ked about h i s work , he
tio n treatment was aga in stopped because the hard and
s m iled and sa id that h e wa s assigned a new assis t a n t
non -elastic end-feel of pro n ation indicated that further
and w a s n o w able to c a tc h u p \vit h a l l h i s o ld files. T h e
improvement woul d not be made \"li th these techniques.
presence of his n e w assista n t s i g n i fi c a n tly reduced
Because of the general im pr ove m ent in his overall
his d a il y stress , and he co nseq uent l y decided to take
fitness, Raii has co ntin ued with his sequence training,
up the sequ e n ce tra i n i n g again on a re gular basis
a tten ding our clinic two to three times per week . His
three times per wee k . He h a d n o ted that th i s general
wrist is now unrestricted d urin g all his d a i ly activi ties.
R EA S ON I N G D I S C U S S I ON AN D C LIN I CAL R E AS ON I N G C OMM ENTA RY
• Clinici ans' answer
To what d i d you attr i b ute h i s dete ri o ration i n sym ptom s ?
There were fin d i n gs of tissue a l t e r a ti ons in th e ce rvi
• Clinicians' answer
c a l and thoracic spines early i n the managemen t, but
R a W s heavy workload a n d h i s frustration vvith the
therefore, local treatmen t was the fl rst priority. Based
the local findings were considered more significant and ,
l a c k of help avai lab le to c o mplete this work seemed
on our c l i nica l experience and the work of Vicen zi no
to con tri b u te to his r ed uced motivation to c o n t i nue
et a l . ( 1 9 9 6 ) , we th ou gh t it possib le to cha nge the
his
self-exercise.
We t h o u g h t
this
a ffect ive state
a n d the red u c tion of exercise were, toge ther
,
t he
sensitivity o f the perip he r y by a pplyi ng m a n u a l tech niq ues to related areas of the spine. The m a i n reason
pr inc i p a l factors responsible for the d e terioration of
ing for a pply i n g spinal
symptoms .
l ower the sensi tivity of the whole wr i st comp l ex .
II
..
C o u l d you exp l a i n y o u r rea s o n i ng rega rd ing the
I I
val u e o f b reaks i n h a n d s - o n treatm ent a s used
Cou l d you com m e n t on t h e reas o n i ng fo r i n c l u d i n g the cervical a n d th o rac i c s p i n e s i n yo u r treatment a t that stage ?
with this pati ent?
Copyrighted Material
mobilization tec hn i q ues was to
1 6 A J U D G E ' S F RACTU R E D RA D I U S W I T H M ETA L F I XAT I O N F O LLOWI N G AN AC C I D E N T
• C l i n i c ians'
earlier a n d had we integrated the p hilosophy of tra i n
an swer
After Ra lf came back to our clinic. local mobi lization techn i ques restored al l m ovemen ts . except pro natio n . Pro n a tion was still res tricted . b u t pain-free. Based on our clinical experience.
v.rith mo b i Lization tec hniques. EarLier in the course of treatmen t . we stopped han ds-on intervention because t h ere was only sli ght improvement. whic h was not sustain ed after t he tre a tme nt. As this observation was consistent over scveral trea tm e nt sess i o n s . we s topped passive mobi lization tec h n i q u es and used a more active approach ( i.e. sequence t ra i ni n g ) .
c o n s i stent with yo u r i n itial p rogn o s i s ? Please exp l a i n why you th i n k i t ulti mately too k t h i s long a n d in h i n d s ight wh eth e r t h e re are a n y a s p ects of th i s pati en t's m a n age m e n t that you wo u l d approach diffe re n tly given t h e s a m e p re s e n tati o n .
The clinicians can be seen here to b e d ra wi n g o n a n orga n i ze d k n o w l edge base th a t combines k n owl edge derived from sim i l a r clinical cases a nd also from relevant research . Their i n ter ve n t io n s a n d associated reassessments
a ga i n
ill u strate hyp o th e
sis t e s tin g that conti nues to occur throu ghout the .
The c l i n i c i a ns critical appra isal of improvement '
made and sus t ai n e d allowed the m to progress their m a n ageme n t from one of h ands-on mobilization
cll1d se l f- m o b i l iz i n g exercise to the more general exercisell1 tness- based approach . It is common that the fu ll picture of
a
p a ti e nt ' s psyc hosocial status
does not emerge at t he s t a r t . As such , the concept of psychosocial screening questions.
answer
The i n i tial prog nosis was fo r
• Clin ical reasoning commentary
on goi ng m a n agement
Was t h e year t h a t th i s p ro b l e m t o o k t o resolve
• C l i n icians'
wo rk, this too may h ave assisted i n bring i n g about a qu icker recovery.
a hard non-elastic end-feel indi
cates that no further improvement is lli(ely to be gained
II
i n g n o t on ly i n t o the speci a l exercises but a lso i n to his
analogous to
screen i n g q u estions for add i ti o n a l symptoms or a
stra i g h tfo rward pre
general health . can ass i st i n identifying pertinent
sentation wi th l oc a l tissue c h a n ges a n d what was
psych osoci al
hy pothesized to be a domi n a n t peri pheral nocice ptive
assessment o f psych osocial
p a i n mec h a n i s m . However. t h e prese ntation turned
blue fl ags' ( Kendall and Watso n 2000; Main and
out to h ave s i g n i fic a n t contrib u ting ce n tr al and a ffect
Bu rton
ive compo nents to the sym ptoms and associated p a i n
Kenda ll. 2 (0 0 ) is still rela t i vel y new, and g reater
behaviours/attitude. W e think i t took so l o n g t o resolve
a t te n tio n to these factors s ho uld strengt h en the
l a rgely because t h e i m p a c t of the overwork situation was u n deresti mated
a n d not a d dresse d .
factors . Ma nual th e ra pists .
yeI I ovv,
'
bl ack
overt and
,
,
2000;
Watson ,
2000;
Wa tson
and
t horoughness of our reasorullg and man agement. The c l inician s ' generou s s h ari n g of thei r reflec t i o n s
I n hindsi ght. i t is probable t h at further probing abou t
on h ow they may have obtained their fin a l ou tcome
h i s workin g s i t u a ti o n and h is associated feeli n g s , and
sooner had they probed this
add ress i n g t h i s i n our management, m ay have a llowed
presentation fu rther from the start is te stam en t to
area
of t he p a t i e n t s '
us to obta i n the same o u tcome in a shorter timeframe.
the self-criticism and wi l li ng n es s to con tinue t o
Had we been able to enco u rage him to fi nd he lp muc h
learn th at i s char a c ter ist ic of experts.
• Refe rences and H a m berg. ). (1 9 8 4 ) . S t retc h i n g i n Ma n u a l Therapy.
Evient h . O. M u scle
A l fta. S wed e n : A l fta R e h a b . Evj e n t h . O. a n d H a mberg. J. ( 1 9 9 1 ) .
Autostrech i n g : The Complete M a n u a l of Speci fi c Stretc h i n g . A l ft a . S wed e n : A l fta Rehab. G u n n a ri . H . . Evj enth. O. and Br ad y. M. ( 1 9 8 4 ) . Se q u e n ce Tra i n i n g . O s l o : D reyers .
K a l ten born . F ( 1 9 9 9 ) . Ma n u a l Mob i l isalion o f t h e Extre m i ty J o i n t s . O s l o : O l a f N o r l i s Bokh a n d e l .
Ken d a l l . N. and Wa tson . P. ( 2 00 0 ) . Identifying psyc b osocial yel l o w flags and m od i fy i n g m a n agement, In Topic a l I s s ues .in Pain 2 . Biopsychosoci a l Assessme n t a n d M a nagemen t .
Pain (G ifford. L. ed .) 1 3 1 - 1 3 9 . F a l m o u t h . UK: CNS Press.
( 1 9 6 8 ) . T h e proce s s i n g 0[' c l i n ical i n formation b y m a n a nd
K l ei n m u n tz . B .
mach i n e . In T h e For m a l Representation of Huma n J u d g m e n t
(8. Klei n m u nlz. cd . ) p p . 1 4 9- 1 8 6 . Ch i c h e s ter. U K : Wil ey. M a i n . C.). a n d B u r t o n . A.K. ( 2 00 0 ) . Economic a n d occupatio n a l i n fl uences
Relationships and
on pain and d i s a b i l i ty. In Pa i n
pp.
M a n a gement: A n In terd iS C i p l i n a ry
Copyrighted Material
CLINICAL REASONING IN ACTION: CASE STUDIES FRO M EXPERT MANUAL TH ERAPISTS
Approach ( C .J. M a i n
and
C . C . S p a n s w i c k . ed s . ) pp.
van den Berg.
6 3-8 7 .
C h u rchi l l L i v i n g stone. McC on igle. T. and Matl ey. K . W. ( 1 9 9 4 ) . Ed i n b urgh:
S o rt tissue treatment a n d m u s c l e
Journal o r M an u al a n d M a n i p u l ative T h e rapy 2 . 5 5- 6 2 . Pfu n d . R . a n d Zahnd. F. (20CH ) . stretc h i ng .
.
Le i tsymptom Sch merz: D i rrerenzierte m a n u a l therape u t ische Un tersllch u n g li nd
Thera p i e b e i
Bewe g u ngss tor u n gen-Kopf.
Beweg u n gs a ppara tes versteh e n u n d beein lluss e n .
Stu ttgart. G er m a n y :
T h i eme.
Vicenzino. ( 1996).
13 . . Co l l i n s. D. and Wri g h t . A. The i n i t i a l e rrect o f a cerv ica l
HWS.
and M a n a g e m e nt Re l a t i o n s h i ps a n d Pa i n ( G i rrord. L . ed . ) pp. 8 5- 1 0 9 . Fa l m outh U K : CNS Press. Watson. P and Kend a l l . N . ( 2 0 0 0 ) . Assessi n g p s ych o social ye l lo w nags. In Top i c a l Iss ucs i n Pa i n 2 . Biopsychoso c i a l A sscssme n t .
s p i n e m a n i p u l a t i ve physiotherapy
B i opsychosoc i a l Assessme n t a n d
on the pa i n and d y sfu n c t i o n of lateral epi co n dyla lg ia Pain . 6 8 .
M a n a gem e nt . Re l a t ionships a n d Pa i n ( G i rford. L . ed . ) pp. 1 1 1 -] 2 9 . Fa l m o u t h . U K : C N S Press.
trea t m e n t
.
6 9- 7 4 .
B r u s tkorb. Arme. Stuttga r t . Cerma ny: Th ieme.
F. ( 1 9 9 9 ) . A n gewa ndte
P hysiologie: Das B i n de ge we b e des
P ( 2 0 0 0 ) . Psyc h osocial pred ictors rrom low back p a i n . I n To p i c a l Iss u es i n Pa i n 2 .
Watso n .
or o ut com e
Copyrighted Material
.
A u n ive rs i ty stu d e nt with
c h ro n i c fac i al pai n M ariano Rocabado
�
S U BJ E C T I V E E XA M I N AT I O N
Pamel a , a n 1 8-year-old girl
i n her fIrst year a t un iver
sity. presen ted with a co m pla in t of chro n ic right fac i a l pain t hat h a d b e e n prese n t for 2 years and treated u n s u ccessfu l ly
by an i n terocclusal or thopaedic appli
ance (IOA , i . e .
a
s p l int) ad mi nistered
by a dental pro
fess ional. The symptoms had developed spontaneously wit hout a ny h i s tory o f m acrotrau m a . Her p a in was local ized on the right m a n di b u l a r ramus without a ny
Area of headache
radiation of p a i n to the cra n i u m or neck areas (Fig.
1 7 . 1 ) . She al so noted occasional earache a nd bilateral temporal headaches. The facial pain was constan t , s h a r p and had b e e n increaS ing i n i n tenSity. Fur ther scree ning revea led n o over t neuro logical symptoms or a ny other are as of symp toms . The pain was mostly felt with atte mpted open ing of the mo uth and was associated with a loud snapping sound . Her symptoms were only felt during the day and there was no repor t of symptoms affec ting her
earAreaacheof
s leep. However, in the morning s he noted an inc reased l imitation of mouth ope n i n g , with increased deflec
of the mandible to the right side. Mastic ation was limited by increased pain associated w i th the biting tion
fo rce s . A ny parafunction a l activity, such as nail bitin g , pencil b i t i n g
and gum ch ewing, produced a grindin g
sensation a n d pain . Her pain sign illcantly affec ted her l i fe , in terfering with her u n iversily work and social
;
and could see the in terconnection be tween her p a in , t h i s stress and h e r biting
parafunctional activities .
None of Pamela 's signs a nd sympto ms had been alleviated at any point by her previ ous treatment with
) .
? ,QrfaciaelaOfpain
activities. She acknowled ged the s tress this created
Fig. 1 7 . 1
Copyrighted Material
N -;:: il
'. 1 , (,
'\
Bod y chart i l l ustrati ng patie nt's s y mptoms. 243
C L I N I C A L REASO N I N G I N ACT I O N : CASE STU D I E S F RO M E X P E RT M A N UA L T H E RA P I STS
t h e IOA . S he r epo r te d that she used the IOA for a p e r i o d of 2 years; howeve r, t h i s h a d n o t red uced her pain o r i m p r o v e d her mandibu lar functio n a l capacity. O n t h e con trary, u s i n g t h e device o n a da i ly basis had i ncreased her rac i a l p a i n a nd precip itated
her headaches, w h i c h had not been presen t prior to the d en ta l craniom a n d i b u l a r orthopaedic treat me n t . Pame la's parents decided to se e k a second opin ion from a n o t h e r spec i a l ist because o r t h is lack o f imp rovemen t.
REAS O N I N G D I SC U S S I O N A N D C L I N I CA L R E A S O N I N G C O M M E N TA RY
II
G i ven t h e symptom a rea a n d the b e h av i o u r a n d
I suspected that they added to Pamela's fr ustration and
h i sto ry o f t h e sympto m s , w h a t w e r e yo u r
in terfer red with h e r socia l l i fe . In a d d ition to the ob vi
thoughts at th i s s tage rega rd i ng poss i b l e
o u s need to ex p l a i n th ese relatio n s h i p s , man agem ent
s o u rces a n d c o n tri b u ting factors fo r h e r
is also go i n g to require ad vi c e to m inimize fu rther irri
sym pto m s ?
tation. For examp l e . d i et mod ification to soft foods and care to avo id excessive open i n g beyo n d 2 5
• C l i n i c i an 's
answe r
mm
wil l be i m p o r tant (e.g. o n ly s m a l l bites and little kisses
G iven her area of symp toms a n d t h a t the [actors
aggravating her symptoms were related to masticat i n g , the str uctures r cons idered as poss i b l e sources a t this stage i n c l uded the temporomandi b u l a r j oi n t (TM] ) , local muscles a n d n e r ves . as we l l a s refe r r a l fro m upper c e r v i c a l spine structures, a l t h o u g h I fel t sp i n a l referra l was l e s s l ike l y g ive n s h e h a d n o spi n a l sy mptoms. I n p a r t i c u lar, I suspected a d isc s u b l ux ation d isorder. with severe intracapsu la r i nvolvement, i n c lu d ing posterior li gament irritation a n d synov i tis secondary to overl o a d i n g of the condyl e. The most li kely c o n tri b u t i n g fa ctors pred ispOSing to and main t a i n i n g her symptoms were her parafu nctio n a l bad hab i ts ( invo l v in g gl iding with load) over a poorly b a l a n ced occl usio n , a n d stress. which she ack n o w ledged ag g ra v a ted her symptoms.
D
At t h i s stag e , did yo u fee l psyc h o s o cial factors may be rel evan t to her p r e s e n tati o n ?
a l l owed ) .
D
P l ease c o m m e n t o n yo u r thoughts regard i n g the wo rs en i ng of t h i s pati e n t's symptoms ( i . e . i n c reas i ng in i n te n s i ty) ove r t h e past 2 years.
• C l i n i c i an 's
answe r
The worsen i n g of Pame l a ' s symptoms over the past 2 years was l ikely the res u l t of a n increase in the i n tra
j o i n t press u re caused by overloading throug h c o n tinued eating of h ard fo ods and her clench i n g h a b i t s
for some patients; w h e n p res e n t to g e ther with a d isc
s u b luxation d i sorder, as I fel t Pa m e l a had , a s tory of worsening symptoms is commo n .
• C l i n i cal
reason i n g c o m m entary
The c l i n icia n ' s a n s we rs t o th e above questions reflect the dy n am i c nat ure of cl i ni c a l reasoning
• C l i n i c i an 's a n swe r
.
Consiste n t with expert. reaso n i n g , he c lea rly for
I fe lt that her fr ustration w i t h the fa i J u re of the splint
to relieve her condition for so long had I U<ely co ntributed to her p ro b lem Stress and asso c i a ted negative feel .
.
These fo rces are s u [f1cie n t alone to create symptoms
m u l ates hy p o t he s e s across a ra n ge of both physi cal and psychosocial issues, i l l u s tr a t i n g both diagn ostic and n a rrati ve reason ing. There is e vi
ings are often man i fest by a b normal parafu nctional activity, such a s cl e n ch i n g and g r i n d i n g , w h i c h a re diffi c u l t for pa tients to avoi d even when they are
dence that even at t h i s early stage hy potheses are
aware of them. The cle nch ing and g r i n d in g then fu r ther con tribute to the proble m both by perpetuating and fu r t her increasing cranioma n d i b u lar m u s c l e act iv ity a nd by becoming annoying symptoms in themselves .
mainte n a nce
bei n g considered with respect t.o sou rces of the symptoms ( e . g . TM} ) , fa c to rs contributi n g to the habits ) ,
of
the
problem
activity/participation
(e.g.
clenching
r e stric ti o n s
(e.g.
so c i a l life) . p a th o b i o l og i c a l mechani sms (e.g. d isc
subluxation) a n d managemen t (e.g. advice ) .
Copyrighted Material
1 7 A UNIV ERSITY STU D ENT WITH C H RONIC FAC I AL PAIN
tE
P H YS I C A L E X A M I N AT I O N
Post u re assessment
Pamela sh owed good he ad . neck a n d shou l d e r g i rdle a l i g n ment. wi th no structural c h a nges that may have contributed to her fac i a l pain cond itio n . Neurological examination A l l neurological tests were negative. Cotton tip appl i
cators
were u s
e d to compare l i g h t touch d i scri m i n a
tion between the right a n d left maxillary. ophth a l m ic
and mandibular bra nches o f the trigemi n a l nerve. Faci a l sensitiv i ty was norma l . Gross hearing was eval u a ted by r u bb i n g a strand of hair between the index finge r and th umb near the patient's ear with no differ e n c e noted between righ t and left heari n g sensitiv i ties. Cervical sp ine examinati on
Upper cervical p hysiologica l and accessory joint mobi l i ty ( L e . CO-C l , C 1 -C 2 and C2-C 3 ) tes ti n g w a s asymptom atic a nd revea led no abnorm a l i ty o f movement. Palpation oj suboccipital triangle. Ab norm ality of soft tissue can be manifest by i ts texture (e.g. hard ness) and se nsitivity or reprod uction of symptoms with palpation. The occiput-atlas space was evalu ated by pal pation. following a li ne of palpation from the centre of the occiput to the tra nsverse process of the atlas. Simil arly. the atlas-ax is space was palpated following a line from the transverse process of the atlas to the spinous process of the axis. With Pamela . Upper cervical mobility testing .
the suboccipital tissues. specificaUy the d eep suboc Cipital rectus capitis. posterior minor, major and left inferior obliquus muscles . were tender to palpation. Ins tability tests Jo r upper cervical region. While stabilizing C 2 posteriorly in fu ll avai lable u pper cer vica l l'lexion. a posteri o r cranial translation was i n d u ced . The same test was then performed stabi l izing the cra n i u m and inducing a ventral glide of C 2 . No displacemen t was perceived or symptoms
provoked with either of these two tests for a n tero posterior tran sverse l i gamen t i nstability. Atla s-axis ra n ge of movement was then assessed by hav i n g the patie n t assume full l1exion of the head and neck and then assessing the range of rotation movement to the rig ht and left ( 4 S deg rees each way is con sid ered norma l ) . Her mobility was approximately 4 S degrees bil atera lly and d i d not elicit a n y sy mptoms. Uppe r ce rvical provocation -alle viati on pain tests .
Co mpression .
d istrac tion
a nd
glid i n g
the
O-C 1 -C 2 reg ion were all asymptomatic a nd j u d ged to be of n ormal mo bility.
M uscle fu nct ion assessment
Gross mandi bu l ar motor function was tested by h av ing the patient clench while palpating masseter. temporalis and dlgastric muscles . Local muscle pain was reprod uced bilaterally from con traction of the posterior and anterior temporal muscles and the right digastric muscle. The hyo id reg ion muscle fu nction was norma l . There w a s no d iscomfort elic ited b y pa lpation of the i n ferior border of the m a nd i ble. the hyoid bone a n d t h e i n lrahyoid region t o t h e ster n u m . La tera l m a n u a l displacement o f t h e thyroi d c a r til age was possible with crepitati o n . This is a c o mmon finding where limited move me n t is i n d icative of abnormality of the infrahyoid musculature. Isometric muscle contraction of the neck flexors. including the suprahyoid and infra hyoid muscles. did not elic it any discomfort. There was also no restriction of cervical movement caused by muscle tightness or hyper activity in the su bOCCipi tal or cervicothoracic regions.
Motor control
Motor control was very good. as assessed by the patient's ability to m.a intain good upper and lower quar ter postu ral alignment d uring fu nctional tasks such as sitting . si tting to standi ng. waUdng and carryi ng loads.
REAS O N I N G D I S C U SS I O N A N D C L I N I CAL REASO N I N G C O M M E N TA RY
D
of
When looking fo r spec ifi c c l i n i cal patte rns
d o you consider as potenti al sou rces for a
associated w i th the TMJ itself, what local ti ssues
pai nfu l TMJ ?
Copyrighted Material
C LI N I C AL R EASO N I N G I N ACTI O N : CAS E STU D I ES F RO M E X P E RT M A N U A L T H E RA P I STS
• C l i n i c i an 's
C o u l d you c o m m e n t on th e abi l i ty to
answer
d i fferentiate s p ecifi c t i s s u e i nvolve m e n t
Several local tissues can be a so u rce of pain s i n c e th ey
th ro ugh c l i n i ca l exa m i nati o n ?
ar e highly i n n ervated and vasculariz e d . • Sy n o v i a l
membrane
a
is
highly
vascul arized
con nective t i s s ue p r o d uc i n g synovia l fl u id
to l u b r i
cate the ar ticular surfaces. • I n fer i o r. a n teri o r or p os te r i or s yn o v i a l tissues can
be p a i nfu l as a result of compres sion of the c o ndy le
when fu n cti o n i n g t owa rd s a n t e r i o r o r p o s teri o r extreme articu l ar p o s i ti o ns . • A n te r i o r. posterior or su p eri o r synovial tissues c a n
become pa i n fu l w h e n t h e
an te r i or
or posteri or
dense edges of the d isc press against the u pper j o int s pace. The d isc tra nsl ate s a n ter io r ly or posteri orly along the t emp o ral eminence d u ri n g fu nc
t i o n a l m o v e m e n t s . Du ri n g protr u S ive and open i n g movements. t h e
an t e r i o r
thick portion of t h e d i sc
encroaches upon the anteros u p eri o r syn ov i a! pouch. po tenti a lly i n d u c i n g a n ter os u p e ri o r jOint p a i n . T h e same situation occurs w i t h posterior translation
of the disc and encroachment of the p o st er o su perior dense por tion of the disc into the postero s u per i o r s y n ov i a l p o uc h duri n g closure with load or d u r i n g cl e n c h i n g . re s u l t i ng i n posteros u perior
j o i nt p a i n . • The articular li g am ents and c apsule that c o n tr ibute to l irn.i t i n g
ar t icu l ar
m ovemen t
are
o ften pa i n fu l as
a res ult of d i s tension s ec o n d ary to repea ted micro trauma ( e . g . p ara fu ncti o n al h ab i ts ) , macrotrauma (e.g. blow to the j aw, p r ol o n g ed opening as with a l en g t hy d ental procedure) or h i gh-vel ocity t r a uma such as a m o t o r vehicle accident.
• C l i n i cian's answer O f co u rse, specifLc t is s u e d i ffere n tiation by c l i n i c a l ex amination is n o t an exact science. Ho wever. I have
d eveloped wha t I call
a
' pa i n map evalu a t i o n ' w hereby
TMJ a r t i c ula r tissue p a i n sensitivi ty and j o i n t mo b i l i ty are assessed by e ig h t sp e c i fi c tests to i n c r i m in a te s p e cific tissues . These tests and t h is pa tie n t 's fi ndi n gs are de s c r i bed be l o w.
• C l i n i cal
reaso n i ng c o m m e n tary
Expertise i n c l i n ical reasoning is closely
linked t o i n i c i a n 's orga n iza t i o n of knowledge. A s evi den t in th e above answer. this k nowledge i n c l u des both proposition a l ( e . g . research-validated biomed ical facts) and non-propos i t ional (e.g. experience
the
cl
va lidated
professional
opinion )
Ski l l e d manual therapy req u i res
a
components.
specialized a nd
rich sto re of both these forms of k n ow l e dge, orga n c l i n i c a l schema or patterns. K n o w l ed ge and r eco gni t io n of a w i de range of often s ub tl y different patterns of c l i n ical presen tation-s uch as those highli ghted i n the answer to q uesti o n 1 above-a llows the expert practitioner to reach diagnostic and other c li n ica l ized i n an i n t e gr a t e d manner as
decisions more e ffic i e ntly and accurately than the novice. This knowl e dge of
clinical p a tt er n s is usu
ally a s s o c i a ted with principles that guide actions to facili tate m ax im a l ly emcie n t testi n g of the hypoth esis fo r m e d and als o to s uggest in tervention strate gies frequently fo u n d effective for that disorder.
Evaluation of the temporomandibular joint
p o l e c a n be fel t . Next. the p a ti ent is asked to mai n ta i n
that contact p o s i t i o n wh i le ope nin g their mo u th 10
Pai n evaluatio n
mm.
W h i ie m a i n t a i n i n g th i s i n i t i a l evaluation
positi o n , the t hera pis t loca tes the s p e c i fic a reas of sort
T h e s yn o v i a l TM} p a i n map sh o w n i n (Fig. 1 7 . 2 ) ill us tra tes th e spec i fic tissues exa mined thr o ugh t h e e i g ht
tes ts descri bed below. The fir s t s tep is to locate the mandi b u l a r c o n dy l e l a teral p o le . Th en , a pp ly i n g gen tle press ure, the therapi s t pl ace s a n i n d ex fi n ger
t i ss u e tenderness u nder assess m e n t . The t h e r a pi s t instructs the patient to ra i s e the ir h a n d as
a
v i s u a l sig
nal if pa i n is experienced when the specific pr o ced ures described below a re per fo rmed (Fig. 1 7 . 3 ) . 1 . Ante roinJe ri o r
synovial
m e m b rane
palpatio n .
r e q u es ts
The antero i n ferior synov i a l tis s u e i s p a lp a t ed with
mandib u l a r protr usion u n t i l the c o nd y l e' s a n terior
the i ndex fin g e r j u st i nferior to the a n te ri o r pole
under
the p a tie n t' s zygomatic arch
and
Copyrighted Material
1 7 A U N I V E R S I TY S T U D E N T W I T H C H RO N I C FAC I A L PAI N
2. An teros upe rio r synovial
m e m b rane
palpation.
While keeping the a n terior pole of the condyle in
MAPA DOLOR ARTICU LAR Prof. Mariano Rocabado
con tact with the index finger, the therapist smoothly moves it u pwards u n til the condy l e ' s anterosu pe r i or edge can be p a l pated adj acent to the i n ferior edge of the articular eminence. S o ft tissue abnor m a l ity detected here is presen t in patients who h ave excessive co ndy l ar movement beyond the i n ferior edge of the ar ticu lar em inence. When this occurs, the d ense anteri o r ed ge of the disc compresses the a n terosuperior
synov i a l
membra ne,
wh i l e
the
excessive condylar translation eventua l ly leads to len gthen i n g / hypermo b i l i ly of the articular c a ps ule . 3 . Lateral Fig. 1 7 . 2
collate ral
l igament
palpation.
Main
t a i n i ng fin ger contact on the lateral pole, the
Synovial tempo romandibular j o i n t pai n
map i l l u strat i ng specifi c tissues that can b e assessed.
therapist then requests the p a tient to open their
1 , Antero i nfe r i o r synovial me mbrane; 2, a n te rosup e r i o r
mouth . Normally during condylar movement below
synovial membran e; 3 , lateral col lateral l i gament;
the ar ticu l a r eminence in ferior ed ge, the d isc moves
4, temporomandibular ligame nt; 5 , p ostero i nfe r i o r sy novial
med i a l ly. a l lowing direct superolateral palpation of
memb rane; 6 . posteros u p e r i o r synov ial membran e ;
7, poste ri o r l igamen t ( d isc b i lami nar zon e ) ; 8, retro d i scal tissue i n s e rtion.
the lateral c o l i ateral l i gament, wh i c h in t he mou th open positi o n is u nder slight d i s tension . Abnormal i ty on p a lpation of the latera l coliateral liga ment is one feature o f a media lly subluxed disc. This implies lateral instab i.lity o f the d isc attachment at the l a t eral po le of the condyle, which, when present, facili tates medial disc d i splacement. 4 . Te mpo romandi bula r liga me n t assess ment. Grip
ping the mandible with the thumb placed intrao rally at the premolar level and the rema i n i n g llngers inJerioriy u n de r t h e mandible, the therapist gen tly moves the mandible i n a n antero posterior direction until the a rticular capsule i s fel t to ' loose n ' o r ' relax ' . Here , fin esse i s t h e key ! O n c e a relaxed position is achieved , the therapist passively gl i d es the mandible (and hence the condyle) posteroi.n fe rior iy. This movement is normally limited by tension F ig. 1 7 .3
I l l ustrati ng pati ent's hand signal to i n d i cate pai n
d u ri ng t h e tempo romandibu lar arti c u lar soft tissue pai n sensitivity eval uati o n .
in the temporomandibular l igament. Pain elicited by this man o euvre i.mplies posteroinferior condyle disc in itial d ispl acement. This initial b i o mechanical displacement o f the condyle o n the posterior dense portion of the d isc i s u s u ally caused by occlusal interferences . If
this test i s positive, the t h erapist
o f t h e condy le. H a r d and ab n o r m a l ly sensit ive soft
must immediately contact the patient's dentist and
tissue is indica tive o f the i n i tial p hase of anterior
commu nicate this cond i tion as there is a high risk
condy l a r hypermo b i l i ty. as occurs with repetitive
that i t may progress to a n anterior disc displace
protrusive m a n d i b u l a r activ ity ( e . g . ora l bad h a b i ts
ment o n the tempora l eminence ( ba sed o n the con
such a s n a i l biti n g , noct u r n a l bru x i s m , etc. ) or
cept that the condyle sub l u xes on the disc a nd the
exaggeraLed mouth open i n g , both of which resu l t
disc sub luxes on the temporal eminence ) .
in t h e co ndyle compress i n g t h e a n tero i n ferior synov i al membrane.
5 . Postero i nJe rior synovial
me mbrane palp a t i o n .
With the patien t ' s m o u th h a l fway open . or i n s l i g h t
Copyrighted Material
CLINICAL R EASONING IN ACTION: CASE STUDIES FRO M EXPERT M ANU A L TH ERAPISTS
l a te r a l exc u r s i o n to t h e opposite side u n til con d y l a r
retrod isc itis , p lu s or m i nus retrodisc a l bleedi n g is
movement is fe l t , the l a tera l pole of the condyle is
impl ic a ted .
i d e n ti fied The therap is t then m oves the p a lpa ti n g .
fi n ger poste roi n ferior ly as fa r as the neck of the c o n dyle a n d assesses for a ny soft tissue a b n orma l
ity. When p a i n is elici ted , it i mp l i e s t h a t either the c o n d y le i s i n an excessively distal ( d or sa l ) posi tion d u r i n g maximum i n tercuspatio n . and hence i rrita tin g these pos teroi nferior
tissues,
sibly as a resu l t of repeated i n terc uspi d a l i n terfer d u ri n g
fun c t io n .
causing
te ro i n fe rio r d is pl acem e nt
repetit ive
m e c h a n i c a l pivo ti n g a n d abnormal co ndylar pos 6. Pos t e rosuperior
Severe d isc subluxation is associated with a posterior condyle-disc s u blux a tion and an emi nence subluxation.
an terior
disc a rticu lar
In more ch ronic cond i tions it is .
also commonly associated wi t h l a teral d isc disp lace men t a n d , less conunon ly, med i a l d isc d ispl ace ment
.
o r that
repe ated pos terior microtra u ma h a s occurred, pos ence
.
.
synovial membrane palpation.
T h e pos teros u perior sy nov i a l membrane can b e
S u m m a ry of pain ma p fin d i n gs Pa mela ' s righ t TMJ wa s pa i n ful to tests
8,
c h ara cteri sti c of
2 . 5 , 6 , 7 and
both cond yle-d isc a n d d isc
tem po ral b o n e su bluxat i ons. Her left TMJ was p a i n fu l t o tests 1 . 2 a n d 3 , c ha ra cte ri sti c o f c o n dyle hyper mo bi l i ty w i t h excessi ve a nte ri or tra nsl a tion
.
p a l p a ted w i t h t h e p a t i e n t ' s m o u t h o p e n . S t a r t i n g a t the p o s t e r i o r edge of the condyle, the ther a p ist moves the p a l p ati ng fi n ge r towards the cra n ium to the top o f the tempora l cavi ty, where the postero
Active physiological movement testing Protrus i o n
.
This occ u r red to 6 mm at the left TIvIJ
s u perior edge o f the condyle can be fe l t . Abnorma l
but wa s l imited to 3
soft tissue sensitiv ity at t h i s p o i n t suggests t h e
tion to the right ( n orma l protrusion is 10
c o n dy le is beg i n n i ng to adopt a posterosuperior posi tio n without disc s u b l u x a t i o n a t the m a x i m um a n gu l ar pOS i t i o n of fu l l o pe n i n g . A pa tie n t w i t h hy peractiv ity o f t h e powerfu l m a nd ib u l ar elevators w i ll a lso prese n t with red u c ed ver tical d imensions ( i . e . posterosuperior d ispl acement of the condy l e ) and sens itivi ty to p a l pa tion 7. Poste ri o r lig ame n t
.
(disc bilam in17r zone) .
The
m a nd i b l e i s a g a i n g rasped w i th the therapi s t ' s t h u m b p l a c e d i n traora l ly a t the premola r leve l a n d th e rem a i n i n g fingers i n fer ior ly under t h e mand i b le. The co n dyle i s init i a l ly moved s l i g h tly i n a d i s t a l (d ors a l ) di rection. r r p a i n is not e l i c i te d . press u re i s th e n a pplied thr ou gh the body o f the m a n d i b l e towards t h e cra n i u m . If this is provoc ative , the most probable s i tu ation is th a t there i s an i n trac ap
mm
Right lateral devi a ti on a t the r i g h t TMJ
.
at the ri ght TMJ with de flec T h i s was
6
mm
mm) .
a o d p a i nfu l
(n or m a l l a tera l d e v i a t i o n is
l O- 1 2 mm). reproduc i n g posterior
j O i n t pain con 7 of
s i s t e n t with posterior l igame n t p a i n a s per test
the pai n map evaluation on the right side. T h is fits w i th t he p resen tation
for po s te r i o r d isp l ace me n t o f
the c o n dyle.
Left la te ra l deviation.
This wa s 3
mm
and p a i n fu l
a t t h e righ t TMJ, co r respon d ing t o p a i n map tests
7 and 8 a nd c h aracte r i s t i c of retrod i s c i ti s c a u sed by compression of the condyle on th e posterior band or the disc. Opening.
There was limi ted open i n g . to 1 8 mm, wit h
pain reprodu ced at the end of the movement. The open ing end-feel was 3 nun with an increase in r i g h t TMJ pain (no rmal end-feel i s 1 - 3
nun).
su l a r i nj u ry w i th a n an te ri or disp l acemen t o f the d i s c on the emin ence and a d i s pl aceme nt o f the con dyle pos teros uper iorly. 8 . Retrodiscal tissue i n s e rti o n .
The procedure for
Passive accessory movement testing La te ra l , medial and a n teropos terior pass ive accessory
7 to eva l u ate the posterior ligame n t
gl id es o f the righ t TMJ were l i m i ted by p a i n from com
is repeated tak i ng the con dy l e toward the poste
press i o n o f the posterior l i g a m e n t of the ri g h t TMJ.
test number
r i or a n d superior z o n e s . This retrodiscal re g i o n
The end-feel was s o ft fo r the l atera l a n d med ial gl id es
is
highly
vu l n e rabl e
a n d the a n teroposterior gl ide was extremely l i m ited
to
i nfla mm ati o n
trau matized .
by p a i n . Long- axis d is traction was asymptomatic
vascu l a r
a nd
and
,
the refore,
bleeding
if
Ma i n t a i n i n g the cra n i a l pressure. the m a n d i b l e is
with normal ra nge o f accessory m ove m e n t . All l e ft
then tra n s l ated a n te riorly. If con d y l a r d ispl a ce
TMJ passive a ccessory glides were asy mptom ati c w i t h
ment w i t h cra n i a l pressure i n creases p a i n . t h e n
no r ma l r a n ge o f movement.
Copyrighted Material
1 7 A U N I V E RS I TY STU DENT W I T H C H RO N I C FAC I A L PAI N
REAS O N I N G D I S C U S S I O N A N D C L I N I CAL R EASO N I N G CO M M E N TARY
II
i n relTodi scitis, associ (click)
Please comment on how your physical/clinical
on the eminence. This resulted
examination fi ndings contributed to your
ated wi th a pain ful posterior li gament. The sound
evolving thoughts regarding this lady's problem.
in the j oint present
with opening , protrUSion and con
tralateral movement of the mand i ble was re lated to a
• C l i n i c i an 's an swe r
reduction of
W h i l e mi nor s i g n s of s u b occipital muscle sensitivity we re ev ident,
the ev idence overwhelm ingly sup
ported a local
TMJ proble m . Her good posture and
lack of a ny i m p a i rmen l i n cer v i c a l j o i n t s . cerv i c a l muscle fu nction or ge ner a l m o t o r con trol led me t o
the displaced d isc. During the process o f
closu re, retraction or d eviation o f t h e mandible t o the same side, the d isc would then re-sublux.
• Clinical reasoning commentary
a nd a n a n terior d i sc
this a nswer i s the clini i n pattern recogniti o n . Competi n g hypotheses (e.g c e r vica l joint i mpairment) are c on s ide re d and ruled out on the basis of i n s u ffi cient e v i d e n ce ; a dominant pattern of i m p airment
tempora l component s u b l uxatio n . The co ndyle was a b le
with associ ated structures involved and patho
the c o n c l u s i o n t h a t she h a d no c e r v i c a l or muscu l ar component t o h e r p resentatio n . The TMJ examin ation was very s tra i ghtfo rward in revealing a c l i n ical pattern of a rig h t posterosuperior condyle-d isc d i s placement to red u ce on the disc. b u t
Pe rhaps most eviden t i n
cia n's
the disc was not able to reduce
skill
physiol ogy i s recogn ize d .
D i ag nostic i m ag i n g facial pain and functio n a l a therapeutic dy n a mic mag
As a resu l t of the chron ic l imita tion o f the TMJs.
netic resonance i m a g i n g (TDMRI) procedure (Fig.
1 7 . 4 ) was performed . r deve l oped the TDMRI protocol mysel f i n order to enhance cl inical examination o f TMJ pro b lems . The TDMRI Ilnd ings further substantiate the clinical p attern suspec ted thro ugh the interview and physi c a l examination
and can a lso assist the manual
thera pist's determinalion of treatment procedures. The
TDMRI protocol was carried o u t with the
patient lyi n g in a supine exami n a t i o n position with her cranium fastened t o limi t movement. A sagittal view was ob tained i n a position o f teeth contact in the
maximum in tercuspatio n , Irrstly w i th o u t the lOA i n mouth b u t l a ter with the applia nce i n pOSition
Fig. 1 7.4
between the teeth . The TDMRl reveal ed a right pos
i m aging (TDM R I ) p roced u re .
terior condyle-d i sc su b l u xation and a n a n terior
Therapeutic dyna m i c magn etic resonance
disc
temporal bone subluxation ( i . e . condyle subluxed posteriorly in rel ation to the disc and disc subl uxed
in maxim u m interc uspatio n , the procedure is repeated
2 0 mm of open i n g and w a s p a i n ful a t 3 0 m m o f open (as signa lled by the patient preSSi n g the paniC but to n ) . However, when performing active pro trus ive a nd
mo u th o pening dy n a mi c exa m i n a tio n . Here
retr u s ive movements. the posterior condyle-disc s u b
anteriorly i n re lation to i ts
normal temporal positio n ) .
A fter perform i n g t h e M R I procedu re w i t h the teeth with
a
the right
TMJ was reduced in the sagittal p l a n e at
ing
luxation was not reduced.
Copyrighted Material
C L I N I C A L REASO N I N G I N ACT I O N : C A S E STU D I ES F RO M E X P E RT MA N UA L T H E RAPI STS
I
� J -
REASO N I NG D I S C U S S I O N A N D C L I N ICAL REASO N I N G C O M M E N TA RY
Please briefly d i scuss you r i n terpretation of h ow
then discussed with the patient and her doctor. T h is is
the TDMRI res ults co rrel ated with yo u r fi n d i ngs
critical to fac i l i tate consensus in u n dersta n d i n g a nd
from the c l i n ical (phYSical) exami nati o n and h ow
comp l i an c e in self- management.
togeth er they gu i ded yo u r ma nagement decisions.
• C l i n i cian's
II
Please e l a b o rate o n the s ign ificance of t h e red u ction d u r i n g the
a n swer
TDMRI
proce d u re b e i n g
a c h i eved w i t h o p e n i ng but not w i t h t h e protru s i ve m ove m e n t s .
The TDMRI co r r e l a ted well with the c li n i c a l ex a mi n a t i o n findi ng s i n th at t hey s u p p or ted a c hron i c al ly sub luxed disc. The p ai nfu l reduction that occur red with the mouth open i n g d uri n g dynamic exami n a t i o n , and t h e l ack of reduction w h e n perfo rm i n g active pro trusive a n d retrusive m o v e m ent s
,
demonstrated
that a ny prev ious th erape u tic r ed u ct i o n pro ce d u r e
.
which t h e patient h a d received h a d , in fac t in creased
her discal subluxation, ca u s i ng i ncreased condy lar compress i o n of the r et r o d i s c a l tissues a n d there by
-
making her i n tr a a r t i cu l a r con d i t i on m o re s e ve re. Since the TNlJ is a three-dimensional co m p l ex j oint,
red ucti o n of the subl uxation m us t also be three dimen s i o n a l . When o b ser v in g the TDMRI . the j oint was red uced at the limit of full opening only when the patient gave a strong active extra effort to open further in the sagittal plane. D uring th e coronal plane s tudy of
the ri g ht joint, it was possible to reduce the rusc w ithou t effort in lateral exc ursion to the opposite side. This reduction in the contralateral movement to the left m ay be used to g u i d e the constTuction of
a reduction sp lin t in
left lateral deviation of 2 . 5 mm . T h e protrusive (hori zontal plane) TDMRI asses s men t showed no reduction
of the co n dy l e-d i s c subluxation . In this situatio n , long a.,\.i s cau dal
di s tra c ti o n is essential p ri or to any manual
reduction p r oced ure in order to stretch the c ap s u l e and allow the condyle to glide over the p oster i or dense por tion of the d is c, thereby achieving reduction without i n tra-articul ar irritation ( non-forceful re d u ctio n )
.
Following the TDMRI ex a mi natio n , it was decided
.
t h a t her IOA would need to be rede si gn e d The exa min
ation fi n d i n gs and recom mended m a n a gemen t were
• C l i n i c i a n 's answe r A reducti o n of the d isc in o p en i n g a n d not by protru
sion reOects the ex te n t of her su bluxati o n , and hence posterio r l i gamentous length e n i n g . A more m i nor sub l uxation will reduce with protruSio n . Pamela c l ear l y had
a
si g n i fican t subluxation that req u ired fu ll open i n g
to red uce, a m u c h more forcefu l activ ity t h a n protru sion. Therefore, i t wa s essen tial that red uction in pro trusion was achieved to avoid fu rther d isplacement of the disc and fu r th er trau ma to the posterior liga ment.
It is a lso fa vo u r a bl e if the reduction o c c u r s d u ring l a te r a l excu rsion to the opposite side as th i s is fa r less tra umatic t h a n a red u c tion in op e n i n g . T h e p a t tern of red uction d u ring the TD M RI s trongly su ggests an exce ntric s pl i n t req u i rement o f 2 . 5
mm
to the l ert i n
order t o achieve red uct i o n .
• C l i n i cal
reaso n i n g c o m m entary
Ma n ua l therapists must con t i n u a lly search for o bj ec ti ve outcome measures to validate t heir c l i n i c a l im pressi on s and monitor their cli n i c a l effk acy. Impressively, th is expert has devised h i s own advanced radiological assessment to correlate with his clinical exam i n ation and assist i n guiding his treatment selection and progression . As com m e n te d on above. this pr ov i d e s another excel lent example of the importance of professional craft knowledge in its own right and as a precu rsor to the d i sc o ver y of n e w biomedica l knowledge.
B;WifB9··tg"-
her u ndergo a manu a l discal reduction treatme n t
As
condylar d i s traction in t h e l o ng a x i s of the j Oi nt.
a
co n s e q u e n ce of the posterior condyle-rusc sub
immed iate ly. The technique performed was a ma nu a l
l u x a tion eviden t on the TDMRl, a d e c i s i o n was made
fol l o we d
to take Pamela out o f the i ma g i ng reso n ator a nd have
moveme n t . In perfo rm i n g th i s , i t is i m po r t a n t to
Copyrighted Material
by
a n terior
a nd
con tra l a tera l
co ndylar
1 7 A U N I V E R S ITY STU DENT W I T H C H RO N I C FAC I A L PA I N
w a s then decided to continue with the second red u
m a i n t a in good i m m o b i Lization 0 (' the patient's head to
It
avoid al tering the preset position of the resonator.
ci ng tri a l using a condylar lateral and med i a l mobiliza
wh ich had already ca lculated the l o n g a x i s of the
tion. In order to red uce t he disc. a three-di mensional
cond yle d u r ing t h e p r e vious TDlvffiI p roced u re This
com bined movement mobi li zation had to be per
red uction test u nder M R I is a sophisticated proced u re
formed to prepare the soft tissues
and expen s i ve because of the extremely long ti me
of space. Chronic subluxated conditions s uc h as t his
.
.
in the three planes
2 h ou rs ) req u i red for the whole process. wbich
u s ua l ly prod uce static or hy p om ob i le disc positions.
i nc l u des initial observations o f t h e MRI. assess men t
so l a tera l a n d med i a l gl id es are necessary to li berate
of images on the screen. bringing the patient out of
the disc i n all planes . T h i s mob i l izat i on was performed
( up to
l atera l pressure appl ied at the leve l of t he
t he resonator to per for m the m a n u a l t hera py p roced
by means of
ure. and then placing the p ati en t b a ck in the res
lingual molar s u rface s . with d i gita l med ial pres s u re
onator for add itional i maging to reassess the effect of
applied at t h e ex terna l condy lar neck of the ri g ht TMJ .
the m anua l t e c h n i qu e o n th e condy le d is c relation . poi nt. My d e c i s i o n to try an d redu ce the disc was
a pp lied on an i ntermittent basis for 30 seco nd s The p a t i e n t s h o u ld not feel a ny p a i n . as i n d eed Pa mela d id n o t . Next. a strong lon g i tu d i na l
pri m a r i ly g u i ded by the coro n a l i m a ge of lateral
distraction tech n ique w i th m a n d ibu l ar condyle con
excursion to the opposite side. which s h owed a good
tralateral and anterior mobilization was performed
condyle-disc red u ction withou t e ffo r t . a n d by t h e
for 3 0 s e cond s . Tota l p roced u re t i m e 5 minutes . After the proced ure. Pamela could perfo r m protr u si ve condy la r movement
-
F u r t her
lack of
man u a l distraclion may be req u ired at t h is
ant
e r io r red uction i n protrusio n .
The techni q u e was .
on t h e r i g h t TM}
fo r t he red uction was
\Jvitho u t p a i n . a nd t he re was an i nc re a se i n her mouth
M an u al d i stracti o n tec h n i q u e
o p e n i ng fro m the p r o t r u ded posi tion
.
wh ich s u g
D i s tract i o n i n t h e longitud i n a l axis i s performed w ith
ges ted d isc red u c tion had been ach ieved .
the p a tien t ly i n g in a supine p osi tion and the head stabilized : tbe t h e ra p i s t s t h u mb is in trod uced a t t he ri g h t pre mol ar mola r ma ndi b u l ar level an d t h e
proced ure would be performed again to confirm
effect o f the ma nual redu ction technique. T h i s is neces
m a nd i b u la r b o d y i s h e l d w i th t h e rest o f t h e h a n d
sary in order to determine the progression of treatment.
( F i g . 1 7 . 5 ) . Cau d a l pressu re is app l ied at the mo l ar
Pamela was again placed into the magnetic resonator
'
-
Pamela was then informed that the complete TD MRI
level w ith simu l ta neou s cranial ly directed pressure
and t he sagittal study wa s repea ted .
g i ven at t h e mand i b u lar le vel .
dyn amics were reassessed . revealing
Pamela was comfortable d u ri ng the mobiliza tion phase of treatmen t a n d no pain was r ep roduced
.
portional lateral excursive and
the
The mandibular
an
i ncrease in pro
protrusive movements
withou t any denections. Her openi ng was now fu ll wit h no pain and only r ig h t facial muscle fatigue. Good anter ior disc--condyle reduction was observed , thus s h ow i n g that long itudinal distraction and condyle mobil ization are of vital im por t a nc e for the preparation of a joint affected by discal subluxation before trying red uction (Fig. 1 7 . 6 ) . The TDlvffiI i s completed w ith dynamic frontal cuts
p erfor me d w i th the p a tie n t in maximu m i n tercus pa t ion
an d max i m u m r ight and left l ater a l m a n d i b u
lar pOSition s . It c a n b e o bserved that a s i g n i lka nt distracter e ffect of the right TMJ condy le is produced w ith left l a tera lity ( i . e .
a ctive l ateral dev i ation to the
left) . as wel l as a right condy le-disc reduction effect
(Fig. 1 7 . 6 b ) . Lateral excursion to the opposite side s h owed very cle arly the c a u d al distraction pos.it i o n Fig. 1 7 . 5
M a n u a l d i s tracti on a p p l i e d in the longitu d i n a l
o f t h e condyle, w i t h a cen t ra l red uction o f the disc
a x i s d u ri ng t h e therapeutic d y n a m i C magnetic resonance
over the condylar head . This reduction condition sug
i magi ng p roced u re .
gests that. for Pame la, the reduc tion p osition i s i n
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CLINIC A L RE ASONING IN ACTION: C ASE STUDIES FROM EXPERT M ANU AL THERAP ISTS
'--'_�I-- Condyle
(a) Temporal e m i nence
Reduced disc Condyle
F ig. 1 7 . 7
Interocclusal orthopaedic appliance (splint)
showing a 2 . 5 mm lateral mandibular deviation to the left in maximum intercuspation.
l o n g itudinal d istraction a n d contrala tera l ma n d i b u l a r l a tera l i ty. T h e refore, the disc m u s t be reduced sa g i t ta lly a nd corona l l y ; o t h erwise the disc i s o n ly p a r t i a l ly reduced in the s a g itta l p l a ne and is not coro (b)
na l ly
F ig. 1 7.6
red uced .
O n ce
discal
red u c t i o n
has
been
a c h i eved , a new lOA is req ui red . This consisted of an
Therapeutic dyna m i c magnetic resonance
im aging illustrating right temporomandi b u l a r joint
upper element with even poin t-sh aped occlusal con
protrusion before (a) and after (b) reduction
tacts in the m a x i m a l in terc uspa tion position and with
treatment.
a l eft 2 . 5 m m eccen tric rel ation of contact ( F ig. 1 7 . 7 ) .
R E AS ON I N G D I S C U S S I ON AN D C L I N I CAL R E AS ON I N G C O M M ENTARY
o
C o u l d you e l a b o rate on the p roced u ra l
(i.e. a t the e n d o f ava i l able mouth opening) as a grade
co n s i d e rati o n s w h e n p e rio r m i n g t h e m a n u a l
II or III ( K a l t e n b o r n , 1 9 9 9 ) mobi lization s h o r t o f p a i n . T h e s u s ta ined d i s traction is then ma i n t a i ned
d i stract i o n tec h n i q u e ?
for
• Clinician's answer
6 seconds and is re peated six times. A min i m u m o f
30 seconds is necessary i n order t o achieve a physio logi
The i n i ti a l capsul ar elon gatio n ( i . e . d i stracti o n ) for r e d u c t i o n p u rposes is perfo rmed while m a i n ta i n in g the pa tie nt s h e a d i n a sta bUized position : t h i s avo ids '
i n terfe r r i n g w i th the MRI tec h n i q u e , Care is needed to avoid exceed i n g the pa tien t ' s pain l i m i t because i f t h is happens muscle g u a r d i n g c a n occur, which i n terferes with the d i stra c t i o n e ffec t . If the procedure is p a i n fu l , distraction i s perfo rmed for 1 second and repea ted six times . The a i m here is to m o b i l ize the c apsule so tha t t h e d istraction reduction c a n then b e achieved
with
cal capsu lar e longa t i o n . If d istraction i s p a i n fu l , a very gentle i n termittent d i straction i s pe rformed short of any resistan ce/stretc h i n g ( i . e , grade I) and with o u t provoking a ny p a i n ,
D
Please d i s c u s s yo u r use o f reasses s m e n t i n general a n d yo u r i n te r p retati o n o f these c l i n ical a n d T D M R I rea s s e s s m e n ts i n parti c u l a r.
• Clinician's answer
o ut i n creasi n g i n tra-artic u l a r pressure, If t h e distrac
It is criti c a l a l ways to reassess the patient's move
t i o n tec hn i q u e is not p a i n fu l . distra c t i o n is begu n as
a
ments a n d sy mptom res ponse fo llow i n g a trea tmen t
sustained longitud inal-type reduction manoeuvre per
p roced u re : t h i s a scer t a i n s t h e tre atment effec t a n d , i n
formed from
maximum articu lar c a psu l a r d i s tension
this c a s e , whether a red u c t i o n
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was
a c h ieved . Ran ge o f
1 7 A U N I V E R S ITY STU D E N T W I T H C H RO N I C FAC I A L PAI N
movement alone i s not su fl'icient t o indicate nor mal i ty of t he
• Clinical reasoning commentary
TMJ. A d i sc c a n be to ta l ly su b l u xed a n d s t i l l
h ave norma l pa tter n s o f moveme n t .
d i scussed i n Chapter 1 . m a n u a l therapists' cra ft 'procedural re a so n in g . The leve l of expert c ra ft knowledge and proced u r a l reaso n i n g renected in the above answers evo l ves thro ugh years o f exper i e n ce with m a n a g i ng these types o f problem. This evo l u t i o n ary process i s . by As
c a se indicated a
T h e TDMRI reassessment i n t h i s
k n o wl e d g e i n forms th e i r
positive reduction erfect of the technique. The TMJ nor mally functions in a 4 : 1 ratio : that is, 1 mm of lateral and
protrusive excursions should give rise to 4 mm of
opening. Follovvi ng Pamela's manua l reduction proce
'
dure, her movements were then consistent with these
necessi ty, fac i litated by reflect i o n upon i ndi v i d u a l
propo rtions and wi t h i n the ex pected normal ra n ges,
cl i n ical experien c es a n d by t he m a i n te n a nce of a n
indic a ti n g a suc c ess fu l reduction
ope n
had been achieved .
m i n d ed b u t critical a pp ro a c h to c l i n i c a l prac While broad g U i de l i n e s . s u c h as d i rect i o n and length of mobilization proced ures . a re established . appl i c a t i o n of t h ese g u i de l i n es are t he n t. a i lored t o the i nd i v id u a l patient presen tat i o n . -
tice.
D
Please explain how 2.5 mm was arrived at as the amount of left lateral ity required for correction in the l OA.
Treatmen t selec tion
• C l i n i c i a n 's an swe r
ures such as r�Ul ge of m ove m e n t wiU n o t a lways be re l iab l e or v a l iel indica tors o f impairment or i mprovement. and as s u c h must be correlated with other outcome measu res such as pa i n . funct i o n a l c h a nge . q u a lity of li fe or, i n t h is case, TDM R I a s s e s s men t Reassessment also prov ides confirma ti o n ( or o t herwi se) o f hypotheses and, therefore, fac i l i tates the a c q u isition of new. or refinement of. existi n g c l i ni c a l pa tter n s an d assoc i a ted action s .
that a discal reduction was observed at 1 0 mm of open .
There fore, if we
take into consideration that mandi bular open i ng and latera l ity no rma l ly ma int ains a proportional relation of
4: 1
progress i o n m u s t be
reassessmen t . as is the case here. Clinical meas
The eccentric condition was determined by the fact i n g Mter the TD MR I reduction phase
a nd
g u i ded by the c l i n i c i a n ' s assessment a nd o n go i n g
(Farrar and McCarty, 1 9 8 3 ) . it m ea ns that 2 . 5 mm
.
of interi ncisal mandibular dev i ation was t h e necess a ry la tera l i ty req uired to reduce the disc without excessive i nter n a l a rticular pressure or intracapsu l ar irritation.
• Stage
2
This stage of management for disc subluxation involved From my experience, while reassessment of the ef fects of specific intervent ions gu ides progression of trea t me n t . th ere a re
specific outcomes that, when achieved
in a p a r ticu l ar order, result in the most efficient a nd ef fective
fi n a l outcome. T herefore, the management
for th i s patient co u ld be descri bed as progres s i n g through seven sta ges.
• Stage
a
comb i n a tion of manual procedures. self-exercise
and splint usage, a l l with the aim o f reaffirming th e condy l e-d i sc position a nd the posterior disc ' s new relation in the fossa. The s p l i n t m a int a ined this rela tio n in a red uced . stabil ized pOSition. The i n i ti a l ti me fra me for this par ticula r patient was that, a fter her fIrst appointment. sh e was treated ( m o b i l izatio n , l a ser and motor retraining) d aily for fi ve sessions to opt i m i ze her abili ty t o we a r the IOA . Pa mel a was a l so i n i
1
t ially se e n d a i ly f o r treatment consisting of ma nu al
For Pa mel a . t h e diagnostic a n d ther a peutic TDMRI
ther a py and l aser d i rected to the retrod isc a l tissues in
were performed on the s a m e day. T h e result was that
order to acceler ate t h e hea l i ng process of these soft
the disc could be reduced witho ut pain
tissues. In a dd iti on , motor retraini n g was utilized v i a
in both pro trusion and l a tera l deviation to the opposite side after
a 'roll
m a nual therapy. This represents the first stage o f
nexib i l i ty, musc u l a r balance/control/rela x a tion
m a n ageme n t . Fur t her treatment was then needed to
disc re m odel i ng in orde r to maximize the effectiveness
improve the c apsu l ar l1ex i b ility a nd motor control in
of the spl in t She was a l so instructed to wea r the sp l int
order to ma i nt a i n this disc red ucti o n .
day
back techn i que (described below) to optimize h er a nd '
l
.
a n d n igh t (i.e. 24 hours) during these 5 days o f
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CLINICA L RE ASONING IN ACTION: C ASE STUDIES FRO M EXPERT M ANU A L THER APISTS
dai ly treatment. Follow ing t h is, treatme n t continued
the h a n d . T he maximum pain less capsular relax
( mobilization , l aser, motor c o n t r o l ) , a l o n g w i t h con
ation position
ti nued use of the splint, for a further 5 weeks. The fo l
gentle an tero posterior movements of the m a n d i ble,
l owin g procedu res and advice were given over these in i t i a l
6 weeks of treatment.
was so ught by m e a n s of sm a l l and
while m a i n taining midway open i n g o f the mou th. Lo n g itudin a l gr ad e I d i straction of the mandi bular
co ndy le was then performed i n th e relaxed capsu
TMJ wi th the pOints of application determined by th e TMJ pain map ( F i g . 1 7 . 2 ) . Poi nts 1 ( lower anterior syn ovi um) ,
traction in a p a i n - free manner, in order to r e a l i g n
3 (lateral c o l l a teral l i g a me nt) , 7 ( posterior l igament
t he co l l a geno u s nbres of t h e a rticu lar capsule a n d
1. In frared laser was used on the r i g ht
l a r (i.e. l oose- packed) p osit i on . The next step was to
perform a g r a d u a Uy increasing longitudinal dis
or bilaminar zone) a n d 8 ( retrodiscal t issue) were
there by al l ow i n g su fficient condy le j o int sp ace for
treated.
the discal redu ction .
2 . Longitudinal distraction was appl ied to the ri g h t
3 . Retrai ning of the articu lar rest pOSition was car
TMJ. F o r t h i s proced ure. Pamela had her m o uth
ried o u t by i n structing Pa mela in pu re condy l ar
h a l f-opened without provocation of p a in. A t h u m b
rot a ti o n , perfo rmed
was then i ntroduced at the right l ower mo l a r level
( i . e. tongue on t h e roof of h e r mo uth) and u p to
and
� o
the ma n d i bu l a r body was h e l d with the rest o f
10
mm
with s u per io r l i n g u a l pl a c i n g
of opening.
R EA S ONIN G DIS C U S S I O N
Please e l a b o rate o n the ' retra i n i ng' c o m p o n e n t
from the eccentric position of left canine--can ine con
w a s in this position of left can i ne--c a nine co n
o f yo u r m a n agement.What w a s the b a s i s of t h e
tact. It
g u i d e l i n e s a s t o the exte n t o f m ove m e n t you
tact t h a t the d isc w a s s e e n t o reduce o n the TDMRI.
req u ested of h e r ( i . e . up to 1 0 m m ) ?
Therefore, Pamela was coached in opening and closure movements not exceed i ng 1 0 mm . Once the movement was learned ,
• Clinician's answer
a
li gh t resistance was added to the o pen
ing in order to red uce hyperac tivity o f the elevator
The active moveme nt of 1 0 mm o f interin c isal open
muscles, which often occurs. This el evator i nhi b i ting
w as at this point d u r ing the TD MRI t h a t the a n t erio r c o n dy l a r rotat i o n was asso
action is critical because, d u r in g the use of the IOA . t h e
c i a ted w i th a posterior disc condyle rotation and suc
mid d l e a nd anterior temporal is, is affe c ted a s i t is sub
cessfu l d isc reduc tion .
j ect t o a forced ma nd i bu lar pOSition . This action could
in g was chosen as it
Pame l a was instructed to produce the p u re condylar
elevator masticatory muscul ature. particul arly
the
be defmed as an expected muscu lar parafunction .
rotation initially from the midline position and then
By the end of the
6 weeks Pamela was a sy m ptomatic
posterior condyle-disc subluxation . Therefore. onc e
a n d h ad rega ined n orma l . fu n ctional range of move
the right joint was redu ced and clinically sta b le, spl i n t
ment. At that point, it was decided to mo di fy the spl int
m od i fi cation ai m ed at retur n i n g her to m idl ine was
to b r in g it back to skeletal m idl ine (cen tre m i d li ne o f
considered necessary in or d e r to mai n t a i n equ a l
the
ma xilla aligned w i th the centre midline o f the
redu ction
i n b oth j O ints. Afte r th i s , Pamela was seen
ma n d i b l e ) . The decision to modify Pamel a ' s splint was
tw ice a week for a fu rther 5 weeks. S he was instr ucted
based on the fact that i n her p resen t off-m i d l i n e s p l i n t
to wear h e r IOA d u ring
pOS i t i o n s h e w a s not i n a comp lete ly nor m a l ized
an even basis) throughout the d ay.
the n ight and for 4 hours ( on
con dy l e-disc relation position . The reduced condyle
Pamela reported having h ad tempora l headaches
w a s s l i g h tly anteri omedi a l while t he contra l atera l
dur i n g the use of the s p lint, which was most l ikely a
side was s l i g h tly p os terio r, placi n g that j o i nt at risk o f
resu l t of the c ha ng e
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of mand i b ular a l ig nm ent and the
1 7 A U N I VE RS I T Y STU DEN T W I T H CH RON I C FACIAL PAI N
muscle adaptation assoc iated with her new m a n d i b u
lar pos i t i o n . As her h ea d a c hes were j ud ged to be t h e
without p a in , as Pamel a was ab l e to do. trea tmen t is the n progressed to the next st a ge.
res u l t of overa c tiv i ty o f the ma nd i b u la r muscles. they were tre ated w i t h a com bi n at i o n of m a n d i b u l ar mus cular res t. by mea n s of the l i ngu a l rest pos i tion . a n d by
t empora l muscle soft tiss u e m a n a geme n t .
• Stage
3
T he aim of sta g e 3 m a n a g emen t is to c o n t i nue w i t h t h e mob il i za t i on and
Use of t h e hype rbo l o i d to p ro m o te
and size of a d i sc. It co mes i n fi ve from 1 to S . nu m b er 5 bein g
d i ffere n t sizes. n u m bered
1 7. 8 ) .
remode l l i n g
and
the conc ave j o i n t s u r fa ce o f t h e d i s c . T h e fol low i n g
T he hyperboloid is a device m ade out of si l i co n e that
the sma l l e s t ( F i g .
and
ens u re t h a t the condyle is fu nc t i o n i ng normally o n
d i scal rem od e l l i n g
resembles the s h a pe
hy p erbo l Oi d exercises i n order to
the d i s c m obi li ty
optimize
Kee p i n g t h e hyperbol o i d
betwee n t he u pper and l ower i ncisors. Pamela was instructed to per fo rm lateral m a n d i b u l a r moveme n ts to the left. w h ich is the position wh ere
a
d isc red uc t i o n
was seen to occur w i th the TDMRL Wh ile in maximum active latera l i ty. Pamela was instructed to perform a 6 second sustained b i ting compression against the
hyper b olOid . T h is a ction s h o u ld be a b solute ly p a i n-free. The aim of this exercise was to u se a c tive compression to pro m o t e remo d e l li ng of the r ed uced d isc. A rter 6 se c onds of b iti ng she was i nstru c ted to r e l ax , releasing the
pressure on the hyper b oloid , and then r eturn to t h e mi dl i ne wit ho ut b i ti n g down . This sequence was then repeated six times and was also performed wi t h an d vvithou t the IOA in t h e mouth. This exercise was con ti nued as seU�management for 2 to 3 d ays u ntil the
next appoi ntment. If the patient performs the exercise
proce d u res were u sed . 1 . Lo n g i t u di n a l di s t r a c t i on wa s pe r fo rmed w i t h the c a ps u l e i n
a
relaxed pos i t i o n . The d i straction was tak
s us ta i ned for h s e c o n d s a nd repecl ted s i x times , i n g c a re t o avoid a ny p r ov oc a t i o n 0 1' p a in .
2 . Longitu d i nal distraction was per formed from a pro trusive and maxima lly ope n ed position without provocation of pai n . In th i s posi tion . maximu m ten
sion is p laced on the c a psule and co l ateral ligaments . l
This e l ongat i o n of the articular cap s ule causes , i n turn,
a dis tract ion of the u pper articular compar t
ment (d isc follows condyle in this case). Distraction is held for 6 seconds and repeated six times. 3. M a n d i b u l ar re l a x a t ion was fac i l i tated by means o f the l i n g ua l res t p o s i t i o n with c o n d y l e rotation ( s i x times) ,
w h i ch a lso enhances
a r t ic u l a r s u rface
l u bric a t i o n . 4 . Gentle
an teroposterior pass ive gl id i n g o s c i l l a t i o n s
were performed fro m the p r otr u sive mid-open i n g p o s i t i o n . Fol l o w i n g 2 years of an i mmo b i l i ze d , s u b luxed d i sc. Pame l a req u ired t h e s e accesso ry gl i d es
in order to mobi l ize her d i sc o n the tem p o ra l emi n e nce. S. Bi ting o n the hyperb ol o i d to fac ilitate d i sc remodel l i n g was p rog ressed from size 1 hyperbolOid to siz e
the p a i n rea cti on to hy p er (i.e. compression) between t he u pper and lower i nc isors. This time, hyperbolOid b i t i n g was 2 or 3 . d epe nd i n g on
b o lo i d bi t i n g
pe r formed fro m
a
po s i ti o n o f m ax i m u m ma nd i b u
lar pr o t r u sio n . If thi s exercise is we l l to lera t e d by
the pa t i e n t , it s u pports the hypo th e s i s t h a t the preSSi n g over the d isc ar t i c u l a r s u r face (a non-pa i n fu l cond itio n ) . ( F i g . 1 7 . 9 ) i l l ustrates t h e hyper b o lOi d b it i n g ' ro l l back' e xe r c i s e : this example dem o ns trati n g retr u sio n perfo rmed [ro m condyle is
a protruded p o s i t i on w h i l e b i t i n g the hyperboloid. Fig. 1 7 . 8
Hyperbo l O i d u s e d in a n i nte r i n c i s a l position
Fig.
1 7 . 1 0 s h ows TDMRI i ma ges of the ri g h t TMJ
while the patient actively p e rfo r m s the red u ction ' ro l l back
in prot r u s io n , p r ot r u s ion w i th b i tin g , a n d retru
exercise' to p rom ote d i s c a l remod e l l i ng.
sion w i t h b i ti n g t a ken a fter 10 d ay s of tre atme n t .
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C L I N I C A L REASO N I N G I N ACT I O N : C A S E STU D I E S F RO M E X P E RT M A N U A L T H E RA P I STS
6 . Hy per b o l o id biti ng was prog r essed to b e ing per
sensitiv i ty
le ss ens .
Once
red uc t io n
has
b ee n
formed s tro n gly in protr u s i o n . then retr us i o n a n d
achieved . mu scu l a r s t a b i l ization exerci ses s h o u l d
fi n a lly i n the incisal position ( b it i n g s us t a i ne d fo r 6
then co n ti n ue for a t l e a s t a fu r t her 6 mo n t hs.
seconds i n each po s i t i o n a n d re p e a ted six t i me s) . This re pre s e n ts the fi r s t s t a ge o f posterior disc a l co ndy la r red ucti o n . ( F ig. 1 7 . 1 0c) d e m on s t r a te s
• Stage
Pamel a 's posteriorly placed disc on the a r t ic u l a r
The a i m of stage 4 m a n ageme n t was to release the
e m i n e n c e . Attention should b e p a id t o teeth sensi
4
ruse from the tempo ral e m i nence. Most c h ro n i c disc
tiv ity. If odonta lgia ( teeth d iscomJort) occu rs . the
s ubl u xa ti o ns are in
proced u re should o n ly be repea ted three times
a c t u a l l y stati c on the ar t i c u l a r e m i n e n c e . The fo l low
a n d then gr a d u a l l y i ncreased to s ix ti mes as the
i n g proced u res were used . 1 . D i st ra c tio n
a
s t a te of hy po mob i l i ty. o r a re
was per fo r m ed w i t h c a p s u l ar re l a x a tion
and mo u t h opened . T h is proced u re is i m p o r t a n t as
a c t ive d i sc-c o n d y l e reduction with the c o l la tera l l i gaments. both medial and l a te ra l . a l l o w i n g the d i sc to acco m p a ny the co ndy le . It a I s o produ ces a sign ific a n t effect o n the u pper compar tment. res u l tin g i n a sepa r a t io n
i t p rov i d es
an
m a x i m u m ten s i o n on
of the a r ticu la r s u r fa ce s between the d isc a nd t he tempora l emi nence. T h i s enhances a r t i c u l a r glid i ng a nd u p per synov i a l a r ticu l a r compartme nt lubrica t i o n .
thereby faci li tati ng
posteri o r d i sc
tempora l bone red u c t i o n . F i g. 1 7 . 9
S c h e m a t i c d i agram i l l u s trati ng proper disc
position (i.e. re d u c t i o n a c h i eved) d u r i ng the hyperb o l o i d b i t i n g exerc i s e p e rfo r m e d i n protru s i o n . T h e a rrows
2. Hy per b oloid b i t i n g fo r d isc remode ll i n g was con ti n u ed with hy per bo l oid s 2 a n d 3 as to l e r a te d . B i ting was performed from a pos i t i o n of left con
i l l u s trate h ow the c o n d y l e and d i s c s i m u l ta n eo u s l y move
tral a tera l mand i b ul a r devia t i o n . fo l lowed by strong
poste r i o r l y when retr u s i o n w i th b i t i n g i s then perfo rmed
b i t i n g from m id l i ne . If t h i s hy perboloid exercise c a n
from th i s p rotr u d e d p o s i t i o n .
Disc
Disc
(b)
(a) Fig. 1 7 . 1 0
Disc
(e)
Thera p e u t i c d y n a m i c magnetic resonance i mage i l l u strati ng r i g h t temporo m a n d i b u l a r i o i n t (TMJ) protr u s i o n .
( a ) Right protr u s i o n w h e re t h e condyle
( C)
red uces the d i s c with a g o o d convex-concave re lation a n d a sta b l e j o i n t
su rface relati o n . (b) R i g h t T MJ protr u s i o n with vert i c a l b i te ( w h i l e perfo r m i n g t h e b i t i ng ' ro l l b a c k ' exe rc ise) w h e re the c o n d y l e i n c reases pres s u re over the con cave su rface of the d i s c , remo d e l l i ng the posterior dens portion of the d i s c . which i s now t h i c ker a n d s l ightly m o re posterior. T h i s effect i s necessary to fac i l itate poste r i o r glide of the d i sc over the arti c u l a r e m i n ence
( EA)
w h e n p e rfo rm i ng retru s i o n with b i t i ng fro m a p rotru ded positi o n . ( c ) R i g h t retru s i o n wh i l e p e rfo r m i ng the
biting ' ro l l b a c k ' exe rc i s e , w h e re d i s c red uction has occu rred . A new relati on between c o n d y l e-disc-fossa is observed . The c o n d y l e is now fu ncti o n i ng s l ightly on the poste r i o r dens portion of the d i s c , but the disc i s i n
a
normal pos i t i o n with
respect to the arti c u l a r e m i nence a n d m a n d i b u l a r fos s a . The fi n a l p roper c o n d y l e-d i s c -fo ssa relation will be obta i n ed with fi n a l orthodontic treatment.
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1 7 A U N I V E R S ITY S T U D E N T W I T H C H RO N I C FAC I A L PAI N
be perfo rmed successfu lly without d iscomfort, the patient can then normally progress to the next hy perboloid exercise. Pa i n at this point is the o nly reference that we have as to whether the patient is performing the red uction procedure correctly and in the reduced condyle-d isc positio n . r r the patient experiences pai n during the protruSive red uction exercise, the therapist must stop the exercise. use d istraction to ease the pain a nd then start again by trying l a tera l excursion to t he opposite side and b i t ing. If these proced u res a re asymptomatic. they should be contin ued u n ti l the next a p p o i n t men t . It is important to keep i n m i n d t h a t the disc i s s u b luxed t h ree-d i m e n s i o n a l ly a n d each exerc ise (hyperboloid biting i n di ffere n t p o s i t i o n s ) can a l te r the d isc pOSi tion . The r efo r e . there is n o rec ipe lo r treatment. Rather. the TDMR I w i l l p rov i d e e v id e n c e of t he d isc s u bluxation a n d req u i reme n ts lor spl int correction. a n d then the various exerc i ses must be trialed and progressed accord i n g to each patient's individual response and tbe res u l ts o f continual reassessment. The aim is to be able to perform aU exercises witho u t pain , which should correlate w i t h d isc red uction as confirmed by TDMRI. 3. The hyperboloid protrusion, biting. tben retrusion only to edge-to-edge anterior incisor relation exercise was carried ou t. If there is no loss of the condyle-disc relation and no pain , the biting should be sustained wh ile a 2 mm retrus ive moveme n t is perfo rmed , fo ll owed by a return to the i n terincisal positi o n . Extreme caution is required with th i s procedure, wi t h the movements and biting force progressed slowly so as to avoid a possible posterior coodyle-disc resubluxation . The strong forces placed on t he pos ter ior ligament with this exercise can cause severe local pain or pain radiating to the ear region U' progressed too quickly. It is of vital importance to keep a finger on the lateral pole of t he condyle of the j oint being treated in order to detect qUickly if a d iscal sublux ation is occu rrin g during this exercise.
• Stage
5
S t a ge 5 , l i ke the other stages. is g u i ded by TDMRI reassessment. In the present case. the TDM RI reassess men t and prog ression of procedu res thro ugh stage 5 were as follows. 1. W h e n the TDMR I was reassessed
w i t h the patie n t in a protrusive position while b i t i n g on the hy perboloid , a hypomobile disc in a n a n terior
d isc-temporal bone posi tion was o bserved . This sit u a tion s u ggested that the protrusive movement with biting would res u l t i n an excessive compres sion of the disc agai nst the articular eminence. Such compressi o n could have been interfering with the synovial l u brication o f the a r ticular surface and , as such, may have compromised the posterior disc-temporal bone reduction process . Fig. 1 7 . 6b shows the c ondy le-d isc red uced positi o n . Biting in that position can produce a hy pomobile d i sc rel ati on. 2 . As a consequence of the disc hy pomobi l i ty, the d is traction mob i l ization was contin ued in tbe open mouth positio n . A fter this. a nterior and posteri o r glides o f the condy l e w i t h t h e d i sc were performed i n order to l u bricate the d isc--em i nence j o i n t s u r fa ce. T h i s tec h n iq ue was ach ieved by graspi n g t h e patien t ' s mand i b l e a n d . w h i l e p r o v id i n g c r a n i a l press ure i n m id-open i n g . pe rform i n g s m a l l osci l l a tory anterior and posterior glides . This proced u re fac i l ita tes the ability or the d i sc to reduce pos ter iorly on the eminence and fo ssa . while the roll back tech nique with the hyperboloid d e v i ce moves the disc b ackwa rds o n the artic u l ar e m inence. 3. Protrusive a nd retrusive movements were nex t per formed while m a i n t a i n i ng light biting on the hyper boloid in order to main tain the newly a c h ieved condyle-disc and disc-temporal bone relatio n s . T h i s a ls o helps t o maintain normal l u brication at the disc-eminence jOint s u rface, which facili tates reduction of the disc by normal posterior sliding. 4 . Reassessment of the lOA reve aled that the eccen tric position ( normal coodyle-d isc-eminence rela t i o n s h i p) was maintained. However. a s a result of d isc hypomo bility a n d the patient's tendency to have tempora l headac h e s . it was decided to add an anterior g u i dance and a canine desocclusion g u i d a nce to the lOA . A n terior g u i d a nce i s a protective mecha nism for the TMJ t h a t reduces the i n tra-artic u l a r pressure wh i c h can occur with des occlus i o n . A canine g u i d a nce is a n a r t i c u l a r pro tection modi fication . When the lateral deviation movement against the c a n i n e g u id a nce i s per for med , a contral ateral articular d istraction effect occurs. Togeth er, the a n terior g u i d a nce a n d c a n i n e g u i d a n c e provide protection against excessive compressive forces (Fig. 1 7 . 1 1 ) . T h i s protective function is p a r t ic u larly importan t d u ri n g parafunctional behav i O u r s , such as g r i nding/ bruxing of teeth when sleep i n g .
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C L I N I C AL REASO N I N G I N ACT I O N : C A S E ST U D I ES F RO M E X P E RT M A N UAL T H E RA P I STS '
posi t i o n was so u g h t where the head m a i ntains a ver tical a li g n m e n t w i th the shoulder g i r d l e . The pro g ression of thera peutic procedures ( ta i lored to the patien t ' s i n d i v i d u a l presen tati o n ) used i n stage 6 was a s fo l lows. 1 . The patient begins w i t h a n terior rotation o f the
occipitalatlantoid j o i n ts ( i . e . u p per cervical flexion or n o d d i ng) . This acti o n a l s o p romotes a n terior rotation of t h e ma nd i b le a nd disc-condyle a n te rior rotati o n . 2 . Lon g i t u d i na l d i s traction w i t h the mouth open and Fig. 1 7. 1 1
Upper i n teroc c l u s a l o rthopaedic a p p l i a n c e
capsular relaxation was conti nued on
with anterior a n d c a n i n e g U i d a n c e .
the i n tra-a r t i c u l a r
cond i tion a n d referred patterns of pain.
• Stage
a nd mob i lity. 3 . Posteri o r disca l self-mob i l ization w i t h the hy per
b o l o i d contin ued with i ncreases in hyperbo loid d iameter ( progress i n g fro m s i z e 1 to 5 ) . provided the disc rem a i ned red uced and the patient was able
6
to tolerate g reater muscu l a r contraction over the
The a i m of stage s i x of m a n ageme n t was to add ress
d isc without joint pain .
fu r ther the temporal component of the d isc derange
4. Pos tural correc t i o n of
ment through exercises designed to fa c i l i ta te good crani a l pos i t i o n i n
a
horiz o n ta l positio n i n space and
i n rel a t i o n to the rest of t h e body. A n orthostatic rest
rF1
concomitant
fa c i l itate supradiscal articular s u rfa ce lubrication
Every new stage of progression of treatmen t was based on conti n u a l reassessme n t o f
a
basis with disc-co n d y l e mobiliza t i o n i n order to
the cra n i u m . neck and
s h o u l d e r gird l e was instigated to i m prove t h e mus c u l a r rest relatio n of the m a n d i b u l a r-cra n i a l cer v i c a l fu ncti o n a l u n i t .
REASO N I NG D I SC U S S I O N
P rev i o u s ly you h a d noted i n you r p hysical
hyo i d muscu l a t u re ac tiv ity. thereby avoi d i n g exces
exa m i nation that t h e pati e n t ' s h owed good
s ive inferopos terior muscle forces
head. neck a n d s h o u l d e r girdle a l ign m e n t. with
It shou l d be kept in mind that the mandible has a supra
00
the mandible.
n o stru ctu ral c h a nges that m ay h ave contrib uted
mandibular muscular relation with the cranium by
to h e r facial pain c o n d i t i o n ' . C o u l d you elabo rate
means of temporalis. masseter and pterygo id muscles .
on the need fo r postu ral correcti o n to
a nd an inframandi bular rel ation with the shoulder gir
i m p rove the m u s c u l a r rest relati o n of the
dle by means of the my l o hyoid . geniohyoid and an te
m a n d i bu l a r-c ra n i a l-ce rvical fu n c ti o n a l u n it?
rior d igastric muscles . This in ferior muscuiar relation is con tin ued d own to the shou l d er gird le through the
• C l i n i c ian's answer
s ternohyoid and omohyoid muscles. Consequently.
Even though this patient did not h ave poor alignmen t
increase mandibular descending a ctivity: si multane
o f t h e cra niocervical reg i o n . to m a i n t a i n a r e s t p o s i
ously. there is rec iprocal mandibul ar elevation ( i . e . an
tion o f t h e m a n d i ble w i t h n o r m a l fu n c t i o n of t h e
opposed action ) . This favou rs the elevator muscle para
changes in the position of the head and an terior neck
i n fr a m a n di b ular mu sculature . it was necessary t o u s e
function and . consequently. teeth contact ( n o rma lly
patterns of movements t h a t would promote
shorter
there s h o u l d be no tee th contact at rest) . This para
distance between the mand ibular symphysi s and the
fu nctional action increases articular in ter n al pressure.
s ternu m . This pos tural correcti o n assists in reducing
thus al tering the expected m a n d i b ular rest position .
a
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1 7 A U N I V E RS I TY S T U D E N T W I T H C H RO N I C FAC I A L PA I N
The postura l a l ignment s h o u l d not i n terfere with the
for thjs mo r e holistic approach, \Nhile pos tu ra l exer
active j o i n t red u ct i o n process. As many patients have
cises are important, t h ey were not mandatory [or this
poor compl i an ce w i t h p os t u r a l exercises . it was i mpor
par t ic u l ar patient g i v e n that her posture w a s quite
t a n t that their p urpose w as exp l a i ned and u n d e r stoo d a n d that the patient was ass i s te d to a p prec i a t e the need
good and hence t he ab nor m a l m a n d i b u lar fo rce was less s i g n i fi c a n t in her presen tation .
• Stage
contractions (held for 6 seconds) for e a c h of the
7 ( 3 m o n t h reass es s m e n t and
progression of t reat m e n t) A lter 3 mo n t h s ,
a
new TIJMR I
was
.
performed to eva l u
(I tt: t h e effects o f t h e l OA , m an u al t h era py a n d self
The TDM R f reve a led goo d
ma n a gemen t exerc ises. red uction (Fig.
of
the d i sc--condy le
a nd
disc--emi nence
1 7 . 12 ) .
The fo l l o w i n g proced u res were used .
.
1 . The lOA w a s mod i fied to a c h i e ve i n terincisal m id
g n me n t with a n te r i o r a n d c " m i n e gu i d a nc e a l i gne d ) . A fter u s i n g t he s p l i n t t h e lOA is mod i fied to set t h e m a n d i b u lae b a c k to m i d l i n e once the con dyle-d isc--e m i ne n ce red uc ti o n is a ch i e v ed . Pame l a w as adv ised t h a t th i s a pp l i a n c e , realigned o n t h e mid l i n e , w a s t o b e u se d on a con t i n u a l b a s i s , 2 4 ho urs a d ay a nd o n ly removed for hygiene p ur p o s e s This schedule o f u s a ge w a s to b e maintai ned fo r a period o f 6 months. 2, N e u ro m u s c u l a r a n d a r t i c u lar emin ence d i s c con d y l e re l a t i o n stab i l ization was conti n u e d . In a po s i t i o n of 1 0 m m of i n teri ncisal o pe n i n g and in m id l ine , Pamela was i n s t r u c te d i n s e l f re s i s te d exerc ises consis t i ng of l i g h t isometric muscle line
agon i s tic a nd antago n is t i c m u sc l e g r o u ps This i nvolved i n termitte n t pressu re g ive n over the lat era l aspect o f the c o n dy l e a n d a n teroposterior resistance to protra c t i on a nd retracti o n , w h i l e tak ing c a r e to avoid r es i s t a n ce of t h e e leva tor mus cles. Isometr i c a l ly d e l ivered resi stance to t h e d e p re s s o r mu scles was used to i n d u c e re l a x a ti o n o f the e le v a tor m u s c l e s 3 , Mter 6 m o n t hs o f s t a b i l i z a t i o n in t he red uced c o n d i t i o n a n d reasses s m e n t o f tbe TMJ p a i n ma p twice a mo n t h , Pamel a h a d m a i n t a i ned t he normal artb ro k i n e m a tic pai n - free 4: 1 ratio fo r m a n d i b u l a r patterns o f protr u s i o n , l a teral exc u r s i o n a n d open i n g . Adaptatio n o f j O i n t s u rfa c e s a n d c o l l agen rea l i g n m e n t to the red uced position was a n t i c i pa ted t o take a fur t her 2 to 3 years.
al i
( s ke leta l mid l i nes
,
.
-
-
Outco.me Pamela has since r e po r t e d by tel e phone that she h a s rem ai ned a s y m p tom atic w i t h n o m a n d i b u l a r limita tio n s of m o t i o n .
CONDYLE
Fig, 1 7 , 1 2
Therapeutic d y n a m i c magn etic resonance i mage of the right te m poroma n d i b u l a r j o i nt. (a) Pretreatm e n t
i mage ta ken i n retru s i o n w h i l e b i ting a n d i l lustrating a s u b l uxed d i s c . (b) I m age at 3 m o n t h s d e m o n strati ng the red u c e d d i s c d u ring retru s i o n w i t h biti ng. I n t h i s position fi n a l sta b i l ization i s m a i n ta i n ed t h rough c o n t i n u e d exerc i s e , s p l i n t t h e rapy a n d orthodontics.
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C L I N I CA L R EASO N I N G I N ACT I O N : CAS E STU D I ES F R O M E X P E RT M A N UA L T H E RA P I STS
• Refe re n ces Fa r rar. W. and McCarty. M . ( 1 9 8 3 ) . A Cl i n ic a l O u t l ine o f Tem po ro m a n d i b u l a r joint D i a g n o s i s a n d Trea tmen t. M o o tgo mery. CA Wa lker Pri n t i n g .
• Suggested
joi nts.
read i n g
Pal acios. E . Va lvasso r i . .
G . E.
.
S h a nnon .
F. ( 1 9 9 9 ) . Manual CA : Wa lker Printi n g .
K a l tenborn.
M . nnd Reed . C . F. ( 1 9 9 0 ) .
M a gnetic Reson a n c e o f t h e Te mporom a nd i b u l a r j o i n t . New Yor k : T h ieme.
Copyrighted Material
MobiliSation
of
the E x trem ity
CHAPTER
18 �
Adolescent hip pain Shirley Sahrmann
S U BJ E C TIV E EXA M I N ATIO N
Steven is a 1 4 -year-old white male with an 18-month
champion and was pa r tic ularly well lmown for his
hist ory of severe bil a teral groin p ain: he was referred
kicks . His karate classes were held t hree to four times
to physical therapy on his mother's insistence. His ini
per week.
tial visit was to his family physician, with subsequent referral to an orthopaedic surgeon in his home town
.
The radiological studies performed by the or thopaed i st
As Steven began to resume p ar ticipation in karate, the previous pain that he had noted occasionally in his right grOin re turned, gradually intensified, and
were negative for hip or pelvic lesions. Steven was
progressed to involve the left groin. The pain in the
then referred to a paediatric orthopaedic surgeon at a
right groin was more intense than that in his left
leading medical centre for further diagnostic testing.
g roin but the symptoms on both sides were severe
The paediatric orthopaedic surgeon was unable to
eno u g h to interfere with h is activities. The intensity
diagnose Steve n s p rob lem and advised him to avoid
continued to incr ease until he had pain when waLk
activity and just to take it easy. Steven had complied
ing for
with these recommendations for over a year, but his
waU< slowly. He also had pain when attempting to lift
'
condition was not improving.
15 minutes at a normal speed, so he had to
either h is left or rig h t thigh ( br ing ing his knee toward
Prior to the severe onset, Steven had been experi
his chest) or when squatting. After
20 minutes of
e ncin g only occasional p ain in his groi n, mostly on
standing, he developed bilateral g roin p ain. When his
the ri ght side. At that time, the pain was not present
symptoms were at their worst, he rated them
d ur ing activity and cUd not interfere with ac tivities
and at their least they
such as walking, running or sports. Then about
8-9110, were 2110. Onc e the severe pain developed it took 30-40 minutes to subside to
20 months prior to his referral, the family experi
the lower level. Steven did not have p a i n when sitting
enced a trage d y involving a nother sibling. Because of
or when in the rec u mbent position. He occasiona lly
the tragedy, Steven did not participate in his primary
experienced pain whe n rolling or cOming to a stand
sport, karate, for 1 month. In fact, the impact of the
ing position from sitting. Any activity that invoLved
tragedy on the family had been so severe that Steven
the upri ght position or flexion of the hips to more
ceased all forms of sports-related activities. His result
than
100 degrees caused symptoms.
ant in activity had made coping with the loss eve n
When Steven and his mother were asked about any
more difficult because he was deprived of an ou tle t for
visceral or health problems, they indica ted that he did
his feelings. The mother also sta ted that being unable
not have any compl aints except for the groin p a i n and
to find any tre atme n t to resolve her son's problem w a s
that his physician had performed a thorou g h physical
ad d ing to he r distress. At the time of his with drawal from participation, Steven had been a karate
out any type of systemic, vi sceral, or genitourinary
examination and ordered other tests that had ruled
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261
CLI NIC AL REASONING I N ACTION: C ASE STUDIE S F ROM EXPERT MAN UAL TH E RAPISTS
disease. Steven had been in good healt h with just the Steven had been
a
quiet and did not volunteer any infor mation that was not req ues ted but answered all questions directl y
usual childhood diseases. good stud ent who enjoyed
and
clearly
.
school and was popula r with his classmates. He was
REASONING DISCUSSION AND CLINICAL REASONING COMMENTARY Two main factors suppor t the belief th<:lt Steve n's
Please discuss your thoughts at this stage
severe
regarding possible sources and contributing
pain was not the result of systemic dise a se
factors to this patient's groin p ain.
muscu loskeletal pathology. First. his symptoms had
or
been present for more than a year: if a seri o u s medic a l
• Cl i n i cian's answer
problem was present. it would be obvious by
Physical therapy treatment or patien ts with hip pain
including extensi ve laboratory and radiological test
now.
Secondly. Steven had been thoro ughly examined,
presents a particular ch all enge because clinical infor
ing. by his physician and two orth opaed ic surgeons.
mation that is available about the causes and character
Therefore. the most IUcely source of Steven's problem
istics of dysfunction is minimal. The prevailing source
was soft tissue. with ongoing persistent irritation
of hip pa in in patients referred to p hysical therapy is
by d ai ly activities. minimal as they were: o therwise
degenerative hip joint disease. Degenerative hip joint
the tissues would have healed in the significan t time
disease is present in older not younger
since the o nset of the symptoms.
individuals. Few
sources of hip or groin pain in the younger individual have been identified. Therefore
.
once systemic and
In a young patient with groin pain who is an ath lete.
c onsid er a
tio n must be given as to how participa
severe musculoskeletal conditions have been excluded,
ti on in a particular
formulating a tentative diagnosis is difficult. Potential
(Wilkerson. 1997). Bec a use of the persistence of the
local sources of pain include muscle s train or injury to
pain after ceasing partiCipation. trauma to the tissues
s port can
lead to the problem
the areas of muscle atta chmen t . such as iliopsoas
during the sport is not an adequate explanation.
tendinopathy, rectus femoris muscle avulsion , adductor
Ins t ead. the sport must have induced changes in
muscle strain. and internal oblique avulsion. as weU a s
neuromuscular control resulting in
pubalgia
precision of moveme n t of the hip joint. Such changes
,
osteitis pubis bursitis cmd local peripheral .
a l teration
of the
nerves (e.g. iliohypogastric nerve. ili oin guinal nerve.
are identified as muscle and movement impairments.
femoral nerve, genitofemoral nerve) (Adkins and Figler.
Though identifying the specific tissues that have
2000; Meyes et al.. 2000: O'Kane. 1999: Polglase et aI., 1991: Taylor et al., 1991). Pain can be referred into the
become p ainful may be useful. it does not address
the
reason these tissues have become symptomatic unless
pelvic girdle area from a wide variety of regions, includ
the presumption is that pure overuse is the cause,
ing the low back and pelvic organs . and by a variety of
which is not likely. The nega tive examination by the
systemic diseases. Systemic causes of hip pain, such as
or thopaedic surgeons for skeletal or soft tissue lesions
spinal cord tumours, ureteral pain. ascites. gastro
suggests that the prob lem must h ave a more dynamic
intestinal bleeding associated with haemophili a and
cause, such
abdominal aortic aneurysm. must also be considered
repeated microtrauma to the joint tissues, rather
(Fagerson.
199R:
Goodman
and
Snyder.
2000).
Musculoskeletal causes of groin pain that require
as
a m ovement impairment that causes
than a severe s t a tic lesio n of tissues. which would be evident by radiological examination.
immediate medical attention include hip avascular
One clinical theory is that repeated movements
necrosis. hemiarthrosis. slipped capital femoral epiphy
and su stained postures alter tissues that control the
sis. femoral neck tractures (Clement et ai., 1993: Goodman and Snyder.
2000: Jones and Erhard. 1996)
characteristics of movement. th us causing movement impairments (Sahrmann.
2001). We have described
and stress fractures of the lesser trochanter and medial
the signs and symptoms of mo vement impairment
femur (Adkins and Figler.
synd romes and contrib ut ing I'actors. based on the
2000).
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18 A D O L E S C E N T H I P PA I N
tlndings of clinical examinations of in d i v idu a l s with
the pattern and consistency of the results Vlrith th e tenta
groin pain withou t systemic or serio us musculo
tive diag n osis .
skeletal pathology. Two main categories of movement
pattern of signs or symptoms is present, then I am more
impairment syndromes have been described. One cat
likely to move on to consider a psychological problem .
If the results are not consistent and no
egory is based on imp a i rme nt s in accessory m otio ns
Steven did not either verbally or p hy sic a lly mani
of the hip joint and the other on impairments in
fest any a n x i e ty, i mpatience or fe ar about his symp
physiological movements.
are
toms or enforced inactivity. nor did he seem Vlrithdrawn.
believed to be impairments of the accessory motions,
This beh av i o ur is in contrast to that of other young
wh ich cause irritation of tissues abo u t the joint. Hip
individua l s whom I h ave seen, in whom d ep res s i on
Femoral
syndromes
syndromes are impa irm e n t s of phys iol og i ca l motio n s ,
was
wh ic h prod uc e pain in m u s c l e s associated vvi th the
pain t o avoid school or any oth e r responsibilities and
a
co n trib u t in g factor. Steven w as not using his
m o v emen t. The femoral syndro mes are na me d for the
was cont i n ui ng to p a r t i ci p a te in social activities.
accessory motion that is believed to be impaired, either
Therefore, I ha d no reason to believe that either
because the motion is excessive or because the motion is
central pain m ech a n i s m s or an emotional co mpone nt
occurring when it should not be. The movement impair
were factors in his p rob l em .
ment, the diagnosis, is attribu ted to the joint developing a particular susceptibility to move m en t in a specifi c direction. Specifi c sports and ac t ivities are believed to
• Clinical
contribut e to par li cular syndromes (Stricevic et al.,
While experts are able to reco g n i z e quickly the
1983). The t he rap i st can formulate a tent ative diagno sis based on how wel l the history corresponds to the
signs and symptoms associated with a specifi c d i a gno sis. The results of the ex amina t ion \i\rill either confirm or
exclude the ten t ative diagnos i s. Similarly, the phy s icicill examin ing a p ati ent who is obese, over 40 years of age . com pl a in in g of po lyu ri a . polydyspia, and pol yphagi a ,
knows the most lil(ely diagnosis is diabetes , and his examination will, therefore , focus on confirming or
exclud ing lhis tentative diagnosis .
reasoning commentary
most likely clinical pattern thr o u gh the process of
induc tive reasoning, they also are thorough in their
deliberations. using deductive reasoning t.o rule out. alLernative patterns, especiaJly t hose of
io u s nature. This is consideration of
a
e v ide n l
more ser
broad range of poss i b l e sources,
including local tissues, tissues cap a b le pain to th e g roin
a
here in lhe clinician's
area
of referring
and more sinist er p atholo
gies. As the clini cian highlights, consideration of
specific sour c e s is important, but give n the lack of det1nitive d i a gnos ti c criteria. particularly for the
D
Given the tragedy that occurred within Steven's family, did you feel his psychosocial status may have been contributing to his presentation?
ated with the pain state. The source of the symp so ft tissue sources are often un able to be confirmed,
No, I did not. My im pressio n was th at this was a ver y
nice, well-adjusted youn g boy, who was dealing as well
as poss ib le Vlrith both the loss of his broth er and the upset associated with his undiagnosed p ain proble m , which had not improved in 1 ye ar in spite of his efforts
recommendations. The characteristics
of Steven's symptoms and his intense participation in karate were consiste n t with a femoral movement impair ment d i agnos i s. Furthermore, he attemp ted to partici
pate
mLlst then focus on p att.e rns of impairments a ssoci toms can and should still be hypothesized. but as
• Cli nician's answer
to follow medical
v ari o Ll s soft tissue s ources of groin pain. re a s oni ng
in activities such as pain tball, which did not require
running. He was not having any trouble in school and was socially active. Therefore, there was nothing to sug gest that psychological problems were contributing to his rondition. I prefer to condu c t my examination and relate
m anagem ent directed to impairments subs t a n ti ated t hro u g h subjec tive and phy sica l evidence
(combined with directed
to
the
reassessment of hypo thesiz e d
interventions
impairment)
is
a rg u a bly m ore va lid . Th e hy p o the sis category 'con tributing fac tors ' also features str o ngly in the clini
cian's
reasoning.
Using
knowledge
of
tissue
he ali ng and questioning that re vealed that the patient's symptoms per s is ted even when sport had
be e n stopped , the clinician has deduced that oth er
factors are l�ely to be contributing to the persistent irritation of the symptomatic tissues. In this case. poss ibly altered neuromuscular control resu lti n g in
muscle and movement impairments about the hip.
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CLINICAL REASONING IN ACTIO N: CAS E STUDI ES FROM EXPERT MANUAL TH ERA PISTS
In addition to this biomedical. 'diagnostic reason
analysis of. potential psychosocial factors. This hypoth
ing', the clinician also reveals her biopsychosocial.
esis is then linked to the likely pain
'narrative rea sonin g' through her attention to, and
are considered to be nocic eptive and not central.
tE
mechanisms, wh ic h
PHYSICAL EXAMINATION
The examination to identify movement impairment
primarily because it is not part of my routine
is a combined examination where a num ber of positi ve findings are necessary to conl'irm the
examination but also because if extension is a cause of the symptoms, they are usually present in
diagnosis. The examination assesses the effects of
standing. Several other tests may help in assessing
syndromes
movements and jOint positions on symptoms, and the presence of neuromuscular and movement impair ments. The examination includes assessment of:
whether lumbar extension is a cause of symptoms. 4. Single-leg standing.
The patient stands on one
leg while flexing the contral a ter a l hip to about 90 degrees and allowing the knee to flex as the
• alignment
knee is brought toward the pelviS. There was no
• movement patterns
obvious hip drop, but when standing on the right
• muscle length
foot, the hip medially rotated, which could be
• muscle strength
observed in a posterior view of the knee. The same
• muscle stiffness
observation was made when Steven stood on the
• pattern of recruitment • presence of a joint's susceptibility to movement
left foot to
a
lesser degree.
in a speciJ1c direction. At the time of his physical therapy examination,
Su p i n e tests
Steven wa s
S. Hipj1exor length test.
l. 78 metres tall, with the last 5 cm added
during the past year. He was slender but well pro
p or tioned , with well-developed thigh and gluteal musculature. The tests are described below and their implications are discussed at the end of the set of tests
in the Reasoning discussion.
the frontal plane. the
With the hip in neutr al in right hip was 25 degrees
short of full extension and painless. When the hip was allowed to abduct,
the hip extended com
pletely. The left hip wa s 20 degrees short of full extension until abduction was permitted, and then the hip extended completely. There was no anterior pelvic tilt during the test.
Stan d i n g tests 1. Alignment.
6. Passive hip al1d knee j1exiol1.
At 90 degrees of
lumbar spinal curves
hip i1exion on both the right and lcft sides, Steven
were normal. The iliac crests were level. without
experienced pain in the groin. Marked resistance to
pelvic rotation or pelvic tilt. The patient stood in
hip flexion was noted at 90 degrees but there was posterior pelvic tilt with lumbar flexion. Passively laterally rotating the hip and applying
Thoracic and
bilateral hip abduction and slight lateral rotation.
no
2. Forward bending.
Motion occurred primarily in
the lumbar spine
wit h h ip flexion limited to 60
pressure on the femur in a posterior direction
degrees. Even with instruction to bend his knees
increased the range or hip Ilexion by 10 degrees
and manual assistance in trying to flex his hips
before Steven experienced pain in the groin. Steven
during forward bending, his hip flexion range of
was instructed to remain completely relaxed du r
motion did not increase. There was no pain during
ing the passive hip and knee flexion. When he did
this movement.
remain relaxed, the pain-free range into hip 11exion
3. Side bending and rotation oj the trunk with the pelvis elicited
stabilized. symptoms
Neither
of
and
asymmetries
no
these
motions were
observed. Lumbar extension was not examined,
increased by 10 degrees. There was slightly less resistance to hip i1exion on the left than on the right side, but Steven still experienced pain at degrees of l1exion.
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90
18 A D O LESCE N T H I P PA I N
7. fictive l1 ip
and Imee flexion.
S teven experi
enced p ain in the groin at 80 d egree s of l1exion of both the right and left h ips. The pelvi s did not ro ta te at a l l during the
movement
11. Abdominul muscle testing.
The upper abdom
inals (internal obliqu es and rectus abd omin i s )
were tested using the method described by Kendall et al. (1993). Steven was able to com
.
When performed passively.
plet e the trunk curl-sit up with his arms folded
the range was limited to 50 d egrees bilaterally
on his chest. which is an 80°1t) or 4/5 g rade. The
8. Straight-leg raise.
and no symptoms were provoked. Monitoring of
lower abdominals (external obliques and rec t us
the greater trochanter d uring the movement
abdominis) were tested with the method described
an ter o
by S a h r m a nn (2001). From the supine position
indicated the trochanter followed medial path position.
an
rather than maintaining a constant
W h e n pressure
was applied at the
inguinal crease to prevent the of the greater troc ha nt er
.
anteromedial pa th
there was marked
resistance to hip l1exion (Fig. 18.1). 9. Iliopsoas muscle test.
with his hips and knees e x tended he was able .
to Ilex and ex te nd his hips and knees b i laterally
.
by
h o l d in g them off the suppor ting surface
and without pelvic tilt. Thi s is c on siste n t with grade 4/5. No pain was reported during the
The te st position of hip
testing.
Ilexion. abdu ctio n and lateral rotation with the
knee e x te nd e d (Kendall et al.. 1993) was used to assess the p erro rmance of t h e i l iopsoas muscle. Steven had difficulty
maintaining the pos i tion
,
thoug h he did not have pain. 10. Tile FABER test.
Side-lying tests 12. Hip
lateral
Jlexiol1.
Th is test is also known as
rotation
from
l1ip
and
Imee
From the position of 45 deg rees of hip
and knee l1exion, Steven performed the motion
Patrick's test pOSition and comprises hip abduc
by move me n t at the hip and without associated
tion/external rotation w ith the hip and knee
pelvic rotation.
llexed (Fagerson. 1998). Steven's range of motion was within norm a l limits. He did experience pain
13. Posterior
gluteus
medius muscle
functio/].
This tested 3/5 on the right s ide and 3 + /5 on the
in the groin at the end of the range for either hip.
left (Kendall et aI., 1993; manual muscle testi ng
No pelvic rotation was evident during this motion
method) (Fig. 18.2). These g rade s mean that
with either the righ t or left lower extre mity.
Steven was unable to maintain the te s t position, which is against gravity. When the hip was
Fig. 18. 1
H a mstri ng shortness con tributing to the
a n teriomedi a l path of the greate r troc hanter during the straight-leg raise. When the therapist a p p l i es p ressure a t
Fig. 18.2
t h e i ngui nal crease t o m a i n ta i n p recise m ove m e n t o f t h e
m edius musc l e. When the pati e n t attempted to resist the
Manua l musc l e test of the poste rior g l ute us
fe mur during the passive straight-leg raise. m a r ked
p ressure a p p l ied by t h e t h e rapist during t h e m uscle test,
resistance from the ha mstrings is evide nt that was not
the h i p m edially rotated and flexed. The patie n t was unable
present without the control of the p roxi m a l femoral
to hold h i s hip in t h e correct position of extension a n d
motion.
l a t e r a l rotation.
Copyrighted Material
•
•
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
70 degrees of l1exion. With v erba l and the alignment of Ste ven s lumbar
placed in f1exion. medial rotation and abduction,
than
his muscles tested 5/5. The Ober test was pos
manual c u es .
itive. with the hip remaining in 10 degrees of
spine and hips c ould be corrected so that the hips
abduction. During the return f ro m hip abduc tion. Steven media lly rotated his hip to achieve
'
were f1exed to 90 degrees 19. Rockil1g backward.
.
When Steven rocked back
ward. his lumbar spine Ilexed but not his hips.
hip adduction.
If the pelvis was controlled by the therapist. preventing
Pro n e
the
lumbar
this
Ilexion.
forced
the hips to !lex a few degrees. Approximately
14. Passive knee j1exion with the hip abducted. No motion of the pelvis was noted and the test
wa s painless. 15. Hip rotation.
10 to 15
repetiti on s
perf orm ed
of
r oc k ing
backward were
with each rep e titi on resulting in a
.
few more deg r ees of hip llexi on. Upon com Lateral rotation of both the right
pletion of the repetitions. Steven's hips flexed
and left hips was 75 degrees. MediaL rotation
to almost 110 degrees without pain in the
range of motion was 10 degrees.
groin.
1 6. Active hip ext en sio n with the knee extended. The hamstring muscle was observed to change its contour before the gluteus maximus. and the hip extended 10 degrees before there was a notable change in the con tour of the gluteus maximus. Monitoring of the greater trochanter
Sitt i n g tests 20. Kl1ee extensiol1.
As Steven extended his knee
in sitting. his hip medially rotated. This rotation
of the femur indicated that it moved anteriorly
is best assessed when the examiner places his
and medially. However. it should be noted that
hands on the thigh while the patient extends
normal reliability studies of assessing the path of
his knee. Knee extension was - 30
the greater trochanter during hip extension or
extension
i1exion have not been performed. To be consid
rotation was pre vented
bilaterally;
when .
the
d egrees 01'
hip
medial
the ra n ge was -35
ered clinically important. the movement of the
degrees of extension. The lumbar spine flexed
trochanter must be at least 1 cm. Van Dillen et al.
during knee extension. but no symptoms were
(1998) have reported that 1 cm variations can be reliably detected by trained clinicians when
elicited. 2 1. Iliopsoas manual muscle test.
To perform
examining pelvic motion and contours of the
this test. the hip is passively Ilexed as much as
lumbar
possible to eUminate the participation of the hip
spine.
Furthermore,
reliability studies of
there
are
few
manual muscle testing.
f1exors that C1ttach in the area of the anterior
although Florence et al. (1992) have demon
iliac spine (Kendall et aI., 1993). The passive
strated reliability in patients with muscular dys
range into hip !lexion was limited because of
trophy. The
pain in the groin and by resistance to flexion.
va lid ity
of these tests has not been
examined.
Both the right and left iliopsoas muscles tested
17. Gluteus maximus manual muscle test.
The
patient is in the prone position with the knee f1exed. The hip is passively extended to 10
3+ / S
.
22. Hip rotation.
Hip lateral rotation range of
motion was 70 degrees bilaterally. Hip medial
degrees and the patient is asked to hold that pos
rotation range of motion was 15 degrees for
ition while resistance is applied to the thigh and
both the right and lei"! hips.
the pelv is is passively stabilized by the examiner
23. Hip lateral rotator mal1ual muscle test. with
The
(Kendall et al.. 1993). The left and right gluteus
hip
maximus muscles both tested 4- /5.
hip positioned at the end of the range to be
lateral
rotators
are
tested
the
tested and resistance is applied to the ankle in the appropriate direction while the distal thigh
Quad ruped 18. Preferred position.
is stabilized (Kendall et al.. 1993). Both the left Steven s preferred pOSition '
was with lumbar spine in l1exion and hips in less
and right hip lateral rotator muscles tested 4-/5.
Copyrighted Material
1 8 A D O LESCEN T H I P PA I N
REASONIN G DI S CU S SION AND CLINI CAL REA SONIN G COMMENTARY
D
How did each test to identify movement
the femoral anterior glide s yndrome , particularly
impairments suggest the principal source or
whe n present without shortness of the iliopsoas
impairment?
muscle. The lack of anterior pelvic tilt. which would indicate a compensato ry motion of the lum bar spine, further supports the hy poth esis that the
• Clinician's answer 1. Alignment.
spine is not th e site causing the pain. As none of
In patients with the femoral anterior
gl ide syndrome, most typically the hip is extended by
a
combination of posterior pe lv ic tilt and hyper
extension of the knees . In the syndrome without rotation, and in the medial rotation subcategory,
the test movements were painfu l a lo ca l neuro genic source (e,g,
ilio hy pog astr i c nerve, ilioin
guinal nerve, femoral nerve, genitofemoral nerve) was considered unlikely. 6. Passive hip
and lmee .f1exion.
These fmdings are
pain occurs duri ng h ip l1exion usually at about 90
consistent wit h the femoral anterior glide syn
degrees. In the femoral
glide syndrome
drome, The passive lateral rotation reduces the
with medial rotation , the h ips are often medially
stretch of the lateral rotator muscles, reducing the
a nterio r
rotated in stan ding. In the la tera l rotation subcate
posterior stiffness and restriction to posterior glide.
gory, the hips are often laterally rotated and the
The pressure on the femur in a posterior direction
pain usually occurs d uring hip extension when
increases the posterior glide, and the subsequent
wa l k ing, In this patient the pain was most notable
increased range before onset of symptoms is con
du ring hip l1exion.
sistent with insufficient posterior glide contribut [f t he pain was from his
2. Forward bending.
ing to the symptoms. The reduction in symptoms
lu mbar spine and occurred during forw a rd bend
and increase in range of motion when Steven was
ing in which excessive lumbar l1exion was present,
relaxed
a possible diagnosis would be lumbar l1exion syn
occurred because contraction of the two-joint hip
drome. Because sus cepti bili ty to rotation is usually
l1exors (rectus femoris, TFL and sartorius) tends to
present in patients with low back-related pain, a tentative diagnosis of l1exion-rotation would be
(i,e.
completely
passive
hip
flexion)
contrib ute to anterior gl idin g. 7. Active hip and lmeej1exion.
Inc re ased symptoms
the one to confirm or disconflfm. However, because
with active hip and knee Ilexion is consistent with
Steven did not have symptoms when bending for
the
ward, although he had excessive lumbar l1exion
femoris and sartorius muscles are believed to be the
motion, this suggests the spine is not the site pro
dominant hip l1exors and not iliopsoas, The result is
ducing the symptoms , but rather the most IU<ely
insu fficient depression of the femoral head. The
site is the hip, The limited range of hip l1exion
lack of femoral head depression causes the femur to
is one of the signs of the femoral anterior glide
impinge on the ante rior joint capsule tissues, The
anterior glide syndrome. The TFL, rectus
lack of lumbopelvic rotation
syndrome . 3. Side bending and rotalion of the trunk with pelvis stabilized.
the
The failure of these to elicit
symptoms was additional support that the lumbar spine is not the site eliciting the pain.
during the motion is
consis tent with the hypothesis that the lumbar spine is not the site eliCiting the symptoms. 8. Straight-leg
raise.
The
painless
limitation
in
range of hip l1exion observed is consistent with aoteromedial
The anterior glide
syn
hamstring muscle shortness, The
drome with medial rotation was supported,
indi
deviation of the greater trochanter during the
intrinsic hip lateral rotators
s traigh t-leg raise is a key sign or the anterior glide
4. Single-leg standing. cating that
the
(obturators ,
gemel li ,
quadra tus
femoris
and
syndrome , The alteration in the path of the greater
The results indicated
posterior glide of the femur during the tlexion
tensor fascia lata (TFL)
motion and because of slight medial rotation of the
piriformis) could be weak or long or both. 5, Hip j1exor length test. marked shortness of
trochanter is believed to occur because or the lack or
iliotibial band (ITB). This is a positive find ing for
femur. The medial rotation of the femur
Copyrighted Material
d uring hip
C L I N I CA L REASO N I N G I N ACT I O N : CAS E STU D I ES FROM E X P E RT M A N UA L T H E RA P I STS
l1exion suggests that the dominant h ip l1exor or l1ex
T h e norma l s tre n g t h of t h e h i p abductor. med ial
ors must be the TIL and possibly the a n terior gl u
rotator a nd Hexor muscles is consistent with the
teus medius and gluteus rrtinimus muscles a nd not
dominant h i p abd uctors bei n g the a n terior g l u
the iliopsoas. which wou ld laterally rotate the hip.
teus med i u s . gluteus m i n i mLls a n d TFL. a n d w i t h
A posi tive test fo r d i m i n
a n evident i m b a l a nce i n h i p musculatu re. The
ished performa nce o f i l i opsoas is a key s i g n o f the
positive Ober test ( t he h i p does not a d d u c t 1 0
9. Iliopsoas m u scle test. a n terior glide syndrome. consid ered
deg rees from n e u tra l ) i nd icates t h a t t h e Hexor/
Pain i n the groin with this test is
1 0 . FA BER test. a
sign
of
h i p jOint
dysfunctio n .
Radiological s t u d ies had ruled o u t degen era tive j o i n t d i sease. b u t the presence of symptoms
media l rotator/abductors are short and th a t the compens atory motion is hip med ial ro tation a nd l1ex i o n . 1 4 . Pass ive knee j1exion with the h ip
a bduct e d .
could indicate j O i n t capsule i r ri t a t i o n . The same
Pass ive l1exion of the knee stretches the TFL and
motion o f h i p abduction/exte r n a l rota tion with
the rectus femoris . w h i le a lso i nd irectly placi ng
the h ip and knee l1exed c a n be accom p a n ied by
tension on the femora l nerve thro ugh its fa scial
pelvic rotatio n . w h ich i s a sign of a l um b a r
i n terface. A b d uction of the hip ind icates that
movement impairment sy n d rome. T h e absence
s h o r tness o f the TFL-ITB caused compe n s atory
o f pelvic rotation during the movement fu rther
motion of the h i p b u t not of the pelvis. This pro
s u pports the hy pothesis that: the spine i s n o t the
vides fur th e r support that the pain i s fro m h i p
site of the symptoms . but that t h e h i p joint is probably respo n s i b l e .
dysfunction a nd not l u m b a r spine dysfunctio n . I S . Hip rotation .
1 1 . Abdominal mu scle testing.
T hese tests pro
The s u rprisi n g fi n d i n g w a s the
extreme ra nge of h ip l a tera l rota t i o n . particu
vide i n forma tion abo u t the musc ul ature t h a t
la rly with s h ortness of the TFL-ITB . which is a
c o n trols pelvic ti lt a n d rotati on . T hese find ings
h i p med i a l rotator m u scle. The extreme range o f
do
not
co n tr i b u te
to
the
d i agnos i s
but
to
the u n ders tand ing o f con tri b u t i n g facto r s . The abdomin a l muscles were tested.
beca u s e the
hip l atera l rotation and t h e b i l a tera l prese n ta t i o n s u ggests possi b l e retrotorsion of the fe mu r. 1 6 . Active h ip extension with the Imee exten de d.
these
The d o rrti n a n t perfo r m a n ce of t he hamstri n g
mu scles were s h o r t . motions such as walk i n g
m u scles a n d t h e d e l ayed o n s e t of t h e gluteus
TFL-ITB m u scles were short.
Because
( when t h e h i p h a s to rotate lateral ly a n d exte n d )
maximus m u scle is a n other i n d ica t i o n t ha t the
would be restricted a n d compensatory motions
musculature that c o n trols the prox im a l end of
wo u l d
be l ike ly to occur. The compe n s a tory
the femur is not fu nctio n i n g optimally. Because
motions wo u l d be l u mbo pelvic rotation. l u mbar
the h a mstri n g muscle attaches to the ischi a l
exte n s i o n o r anterior glide a t the hip j o in t . The
tu beroS i ty a n d t o the tibi a . t h e d i s tal e n d o f the
strength o f the abd o m i n a l s a n d the lack o f
fe m u r c a n move posteriorly without the p rox i
symp toms
the
mal e n d of the fem u r m a i n t a i n i n g a consta n t
lu mbar s p i n e is not t h e s ite o f compensation o r
during
tes t i n g
s u ggest
that
p O S i ti o n . The a n terior/ med i a l m o t i o n of the
t h e sou rce o f symptoms. W he n the l u m b a r spine
g reater troc h a n ter s u pports the hy pothesis that
is the s o u rce of symptoms. a strong contraction
the hip musculatu re contro l l i n g the proximal
o f the il iopsoas muscle usua l ly produces symp
end of the fem u r ( the g l u teus m ax i m u s . piri
toms, probably because o f the a n terior shear a n d
formis and lateral rotator muscles) is n o t partici
compre s s i o n fo rce s .
pating optima l l y and i s permitti n g i n a p p rop r i a te
1 2 . Hip late ra l rotation fro m h ip a n d knee j1ex i o n .
Because Steven prefere n t i a lly moved the h i p a nd d i d n o t demon strate pelvic rotati o n . this s u p
motion of the proxi mal femur. 1 7 . G l uteu s maxi m u s manual m uscle test
The
fi n d i ng of gluteus m aximus mu scle weakness
p o r ted the hy pothesis that t he l u m b ar spine was
i nd icates that the pattern of muscle participa
n o t the s o u rce o f the sympto m s .
tion
1 3 . The poste rior gl ute us medi us muscle . ma rked
wealmess
of
the
posterior
The
gluteus
medi u s i s a contri b u t i n g fac tor to the fe moral a n terior gl i de s y n d rome w ith m e d i a l rotati o n .
during
hip
extension
w i th
the
knee
ex tended is consistent w i t h weakness o f gluteus maximus. 1 8 . Prefe r red POSitiOIl .
The assu me d position o f
l u m bar flexion a n cl l e s s than 70 d e g rees of h ip
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1 8 A D O LESCENT H I P PAI N
flexion is consistent with resistance to posterior
c a n n o t provide fi n e control o f femo r a l h e a d
gl ide of the fe m u r and that the l u m b a r spine
m o t i o n nor c a n t h e y stabilize t h e femoral head in the acetab u l u m .
flexes more e a s i ly than the h ips . T h i s i s also a common fi n d i n g i n tile l u mb a r flex i o n sy nd rome
2 2 . Hip
The
rot a t i o n .
excessive
hip
l ateral
a n d i s , therefore, not spec i fic to the fem o r a l ante
rotation a n d l imited med i a l rotation ra n ge a re
rior g lide syndrome.
prese n t in the exte n d e d h i p position and in the
1 9 . Ro c 1d n g back ward.
flexed hip position; this su ggested that S teven
These results are a key
sign of the fe moral anterior gl i d e syndrome.
had retroto r s i o n of b o th h ip s . Accord i n g to a
The resistance to hip flexi o n is attributed to sti ff
study of
ness o f the posterior s tr uctures o f the hip. In
Hekkar ( 1 9 8 7 ) , m a rked asymmetry o f medi a l
the quadru ped position , the we ight o f the pelv i s
vers u s l a tera l hip r o t a t i o n ranges o f motion ,
and t h o r a x h e l p s to bring the acetabu l u m d ow n
with either the h i p extended or flexe d , in d i c a tes
hip a n tetorsion by Gel berman and
over t h e femoral head. w h i c h is not possible
hip a n teversion . B y i n ference, an asymmetry
when the patient is i n the supine position and
o f greater hip lateral rotati o n ver s u s h i p med i a l
flex i n g h i s
hip. The greater ra n ge o b ta i n ed
rotation i n the h i p flexed and extended posi
with o u t g ro i n p a i n i n di c a tes t h a t when the
tions would a l so support the presence of h i p retrotorsion .
fe m u r does posteriorly glide, the symptoms are red uced .
2 3 . Hip lateral rotator m a n u a l m u s cle test. Wea k
2 0 . Knee extension .
ness of the hip l a teral rotator muscles is con
The medial rotation of the h i p
d u r i n g knee extension is a n other indication of
siste n t w i th
the domi n ance of the hip med i a l rotato r s . When
t h e h i p.
the
med i a l rotation
pattern
of
the med i a l rotation was prevented , the knee extension
range
of
motion
was
decreased.
Conseque n t ly, a nother factor c o n tr i b u tin g to the
D
rotation was that the med ial h a m s t r i n g s were shorter than the latera l h a mstri n gs . However, both the medial and latera l h a mstrings were
P l ease s u m m a r i ze yo u r p r i n c i pal d i agnosis at the e n d of the phys ical exa m i nati o n .
• C l i n i c i an 's an swe r
short, as ind icated by the l i mi ted knee extension
The fi ndings of the exa mination are c o n si s te n t w i t h a
ra n ge of moti on. T h o u g h the l u m b a r spine
d i a g n o s i s of femoral a n terior glide sy ndrome w i th
flexed d u r i n g knee exte nsion , Steven did not
medi a l rotatio n . I n this syndrome, the p a i n i n the
experience a ny sympto m s , i n dicating that the
groin is believed to be c a used by the h e a d o f the fem u r
l u m b a r s p i ne was pro b a b ly n o t the site of his
fa i l i n g to gl ide posteri o r ly d u ring Ilexion a nd during med ial rotatio n , a n d t h u s impinging o n the a n terior
sympto m s . We akness of
j o int c a p s u l e tissues. The sy ndro me develops because
il iopsoas i s a key sign of the femoral a n terior
o f the repeated movemen t o f h i p Ilex i o n /med i a l
2 1 . Ili op s o a s m a n u a l m u scle test.
gl ide synd rome. The compromised performance
rotati o n . T h e repeated movement i n creases t h e per
o f the i l i o psoas muscle is another factor con
formance and th u s the dominance of the TFL and
tribu t i n g to the diminished control of muscles
other medial rotators . The muscles that attach c l ose
attach i n g close to the axis of rotation a n d that
to the axis of rotati o n , such a s iliopsoas, gluteus max
s tabi l i z e the fe mora l h e a d in the acetabu l u m and
i m u s and the hip lateral rotators ( i nc l u d i n g piri
preven t med i a l rotation . The i l i opsoas muscle,
formi s .
through its attachme n t to the lesser troc ha nter
femor i s ) , become weakened and/or l e n g thened and ,
the gemel l i ,
the o b t u r a to r s a n d q u adrus
and the path of its muscle fi b res over the fe moral
therefore, fa i l to maintain precise control of
head, contri b u tes to stabilizing the head and l at
femoral h e a d . A n a d ditional contri b u ti n g fa ctor in
the
era l ly rotating the fe mur. In c o n trast, the other
S teven was stru ctural hip retrotorsi o n , which l i m
h ip Hexors ( rectus femoris, TFL a n d sar torius)
i t e d t he n o r m a l r a n ge o f medial rotati o n . A n activ i ty
attach to the an terior i l i a c spines of the pelvis
that
and
kick in kara te, req u i re d an abnormal r a n ge o f hip
to
the
tibia
via
tendons
and
fa scia.
requ ired
hip
medial
rotatio n ,
such
as
the
Therefore, these muscles. w h i c h attach at a dis
motion for this patie n t , thu s predispo sing him to the
tance from the a x i s o f rotation of th e hip j o i n t ,
syn d rome.
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C L I N I C A L R E A S O N I N G I N ACTI O N : C AS E STU D I E S F RO M EX P E RT M A N U A L T H ERA P I STS
The fi nd i n g s consiste n t w i t h the d i a g n os i s were :
sca ns or o t h e r ty pes of s p e c ia l ra d io l og ic a l tests fo r d etec t i o n . It is es t a bl i s h e d by 6-� years of age. Wide
• p a i n w i t h pass ive h i p flex i o n at <J (}- 1 00 d e gre e s
v a r i a t i o ns i n fe m ora l tor s i o n have been re p o r t e d .
• d e cr e a s ed p a i n w i t h increased ra nge of p a ss ive
a nd conserva tive meas u res to mod i fy tors i o n h ave
the hip is l a tera lly ro tated a nd
( K l i n g a nd Hens i n ger. 1 9 � 3 : 1 9 8 5 ) . The c o n d i t i o n h a s not been s h o w n to res u l t in h i p j o i nt d i sease an d . consequently. is n o t consid ered to be of i m po r t a n ce except in e x treme c a s es . Steven w a s a k a r a t e c h a mpion with p ar t i c ul a r ski l l i n the kiclc. The k a ra te kick i nvo l ves
h i p llex i o n if
press u re is exer ted on t h e femu r i n
a
p o st er i o r
d i rec ti o n • a n teromed i a l d e v i a t i on of t h e greater t r oc h a n t e r d u ri n g h i p flex i o n : increased resistance to h i p flex i o n if t h e axis or rotation is m a i n t a i n ed by pass i ve
• s h o r t n e ss o f t h e ha m s tr i n gs
effect ive
tura l hip retrotors i o n . the re p e a t e d rotations a l tered
• s h or t TFL-ITB . we akn ess of t he i l i op so a s m u s cl e
the mu s c ul a r control and p res u m a b ly the precision of
med i us musc l e a n d strong
fe mora l accessory motio n . These p r e s u m p t i on s a re b a sed on the r esu l ts of the e x a m i n a ti o n that h a s been
h i p a b d uctor/med ia l rotator m usc l e s • s t i ffn e s s of t h e T t'L . which c a u sed the h i ps t o
described . O n ce the patte r n of femoral molion h as
abduct when the knee was flexed w h i l e the pa tient
become abnorma l , w i th an terior glide in t h e d irection
wa s in the prone position
of motion that is t h e p a t h of le a s t resistance. t he
• excess ive h ip l a t e r a l rotati o n . which i n d ic a ted the
A d d i t i o n a l con tri b u t i n g factors t h a t we re e x plo r ed
• g l u t eu s m a x i mus m u scle we a kn e ss • d om i n a n c e
of
h a ms t ri n g
musc l es
a n teri or j o i n t c aps u le t i ssu e s are s u bj ected to repe ated mic rotra u m a and thus i n j u ry.
p a t i e n t had retrotorsion of the fe mur d u ri n g
hip
ex tension
a fter the i n iti a l exam i n a t i o n su pp o r ted the di a g n os is . S teven slept on h i s s i d e w i t h h is h i p a d d u c ted a n d
t h e qu adruped p o s i t i o n
m e d ia l l y rotate d . He a l s o sat w i t h h is legs c r o ss e d so
t h a t i m p roved ( i ncrea sed hip flex i o n r a n g e o f moti o n w i thou t s y m p t om s ) with the exami n er assisti n g r e p e a te d attempts to rock b a ckwa rd to ensu re t h a t t h e h i ps were J1ex i n g and n o t the
th at t h e a n kle of one l ower extremity was on the
• l i m i t ed
•
been
Staheli e t a l . .
hip medi a l rotation and because Steven h a d struc
pressu re exerted by the exa mi ner
• weak posterior gl u t e us
not
hip
i'lex i o n
in
t h ig h of t h e o t he r lower extremi ty. Even t h o ug h t h i s is l a tera l rotation. t h e accessory m o t i o n is a n t e rio r
gl i d e . Th ere for e , even this pOSition is contri b u t i n g to
l u mbar spine
the a n terior glide of the femoral h e a d . When sitti ng.
hip m e d i a l rotation d uri n g k n e e exten sion
h e d id n o t h ave his h i ps flexed to 9 0 d e g ree s b u t was a lways i n a s l u m ped . s l o uc he d pos i t i o n with only about 60 d eg r ee s of h i p l1ex ion .
• we a k hip l a teral rotators. • h i p re tr ot o r s i o n , w h ich is a p a th o l o g ic decrease i n t h e n o r m a l 1 4 degree a n ter iorl y d i rec ted a n g l e of the h e a d
and neck o f the fem u r w i th r es p e c t to the
t r a n s ve r s e axi s of the femoral c o n dyles
• a n ter i o r d u ri n g
movement
hip
of
e x t e ns ion
the
greater
troch a n ter
(the
greater
t r oc ha nt e r
should rema i n cons tant or move s l i g h t ly p o st e ri
o r l y as the gl u teus ma x i mu s a n d piriformi s muscles control i ts p o s i t i on and preve n t the med i a l rotation or an te r i o r gl ide of the femoral head ) : w h e n a n abnor mal p at t er n of re c r u i t m e n t
a nd muscle per
formance is present, the motion of the fem u r is s i m ilar to a see-saw, w i t h the p r o x i m a l e n d moving i n a n a n te ri o r d irection and t he d i s t a l end m o v i n g in a posterior d i rection .
• C l i n ical
reason i n g com mentary
Having been a sked to c o m m en t on h o w each of the above tests specitlcalty s u pp orted or did not s u p port her principal hy p o thesis regard i n g the most l i kely source of pain and dysfunction or im pair ment, the clinician has nicely demons trated the evo l vi ng n a t ure of her reaso ning. That is. wh ile the femoral anterior glide s y n drome was n o te d
exami n ati o n , each te st of the p hy s i c a l examina
then in t e rp reted with respect to whether this hypothesis. Reasoning c a n be seen t o occur with every ex amination p ro ced u re , i n t his case rei n forcing tbe p ri n c i pal t i on was
it d i d or did not support
The t o r s i o n of the femur ca n n o t be seen on s t a n d a rd r a d i o g r a p h s a n d req u i re s c o mp ut e r to mo g r a p hy
as
the most likely impairment based on the subjective
Copyrighted Material
1 8 A D O LESCE N T H I P PA I N
hypothes i s . A sec o n d ar y hy pothesis of l u mbar spine
factors that con tribu te to the development and mai n
patients' problem s . Here the cl in ic ian has find
i mp a i r me n t wa s a l so b e i n g s i m u l taneously tested .
tenance of
indica t i n g t h a t the c l i n i c i a n
outlined a n extensive list of p hy s ic a l examina tion
was
open to other poten
fP'
i n gs associated w it h her principa l diagnostic hypothe
tial expl a n a t i o n s for the patien t ' s presen tation . rich store of
s i s . 'I'he pr o cess is a lmost ma de to look simple, where in
(arm
prototypes of frequen tly experienced s i t u a tio n s These
real ity t he re is m u ch overlap between the fea t u res of different clinical patterns; distinguishing between
to recogn ize. in terpret a n d respond to ot her physiotherapy, pattern s exist in cl a ssi c
examination , treatmen t a nd reassessment. Being the
Experts in all
professi o ns possess
a
patterns wit hin thei r a rea of expertise, wh ich .
a re used
si tua t ion s. In
diagnostic syndromes.
in associated management
st rategies. i n pathobiologieal mechan isms associated
w it h those
men t a l .
syndromes. and in the phys i c a l environ .
psychosoc ia l ,
behaviomal
and
c u l tural
co mpe t i n g patterns requi res thorough and systematic
first to identify a clin ical patter n .
as
thi s exper t
can
be
credited with . req u ires more t h a n j u st years of experi ence. Such
a
contri bution to the profession req u i res
skiUed . rellective cli n ical reason ing.
2. Hip ex te n s i o n i n prone. S teven l ay w i t h two p i l l ow s u nd e r his a b d omen so The
m o v e m en t i mpairment d i a g nosis d i re c ts the
treatme n t because i t i d e n t i fies the mov em e n t d irec
tion t h a t must be corrected . T h e refo re the main goal .
of the m a n a ge m e n t progra mme was to i m p ro ve the po steri o r glid e o r the femora l head . preve n t excess i ve a n t e rio r g l ide. e l imi n a te the e xc e ss i ve med i a l rota tion, and r es tor e the correct p a t tern of m u sc l e l e n g t h .
stre n g t h . a n d p a r tiCi patio n . In order t o ach ieve t he se go a l s . the home exerc ise p ro g r a m m e i n c l uded per for m i n g the tes t moveme n ts t h a t we re posi tive. The
mo ve men t
patte r n s
and
p os t u r e s
u sed
in
d a il y
activities that c o n tr i b u ted t o t he devel o p m e n t o f t h e sy nd rome a lso needed t o be corrected . A p a r ticu l ar l y i mpo rta n t exercise was roc k i n g backward in the q u a d ruped position wi t h the mo t i on occurring i n the
h i ps and not i n the l u mb a r spine. Th i s exerc i s e fo rces the fe mur to move in a posteri o r g l id e by s t re t c h i n g the
sti ff
a n d/or
s h o r te n e d
posterior
An o th e r impor tant exercise was
stru ctures.
hip abduction w i t h
la t er a l rota t i o n pe r forme d i n the side ly i n g pos i t i o n . -
O n c e S te ven h a d a t l e a s t 1 1 5 d e g r ees 0 1 h i p llex i o n
w itho u t p a i n . he would b e g i n exercises to s t ren g t he n the iliopso a s m u sc l e speciltcal l y. At the t i me of hi s i n iti al v i s i t Steve n was i n s t r u c ted
in t he fo l l owi n g exerc ises.
his h i p s were ll exed . He t h e n
per formed h i p e x t e n s i o n w i t h h i s k n e e exte nded
a n d with the e m ph a s is o n i n i t i a t i n g t h e motion with t he g l ut eu s maxim u s muscl e. He was t a u g h t
to m o n i to r t h e path of the g re a te r troc h a n ter a n d not t o a t tem p t m o r e t h a n 1 0 d e g rees of motio n . 3 . G lu te u s med i u s mu s c l e. S teven w a s p o s i ti o n ed i n side ly i n g with two pil lows betwee n h i s k n ees a n d
t h i ghs ( s o t h a t his hip w a s i n abd u c t i o n a n d s l i g h t l a te r a l
rota tion )
and
w i t h h i s knee llexed
to
a pprox imately 30 d eg r e es . He w as taught to p a l p a t e the g l u t eus med i u s muscle bel ly a nd to b e s u re he could fee l it become fi rm when h e a t tempted to
abduct a n d l a terally rota te h i s h i p . 4 . Knee exten s i o n i n s i t ti n g . T h i s wa s p e r fo rme d
w h i l e m a i n t a i n i n g s l i gh t h i p la ter a l rotatio n . He w as i nstructed to ' t h i n k abou t o n ly u s i n g a few fibres of his q u a d rice ps to e x t end his knee. Th i s '
d irecti o n w a s g i ve n t o preve n t ex aggerated u s e o f the d omin a nt rec t u s fe moris a n d TF L muscles. 5. Hi p llex i o n . While still sitti n g : he w a s i n s tructe d to use both h a n d s to l ift pas s ivel y his h i p into ll e x i o n
b u t to s t op i f he fe l t p a i n i n his g ro i n . 6 . H e w a s show n h o w t o u s e a l i g h twe i g h t s t re tc h cord for res istance to h ip l a tera l rotation wh i l e
sitting. 7. A ct ivel y c o n tTac t i n g the mu scle s in t h e g l u te a l
1. Quadruped rock i n g b a c kward with e m p h a s i s on
h i p ll exion a n d av oi d i n g l u m b a r llexion . Steven
area t o preve n t h i p me d i al ro ta ti o n wh i le sta n d i n g on a s i n gle leg.
rocked backwa rd to t he point of pain in t h e groi n .
A l l exercises were to be p er ro r m ed 8-1 0 t i m es tw ice a
p osi tio n a n d
day. In a d d i t i o n . S te ve n was i nstructed to sit with h is
H e t h e n rocked back t o the star t i ng repea ted the exerci se.
h i p s llexed to 8 0-9 0 de g rees and to avoid cros s i ng his
Copyrighted Material
C L I N I CA L REASO N I N G I N ACT I O N : CASE STU D I ES F R O M E X P E RT M A N UAL T H E RA P I STS
l e g s . When si tting he could lean forward by O e x i n g his
• p erform ing forward bend i n g wh e n s tan d i n g by
hips if he p u s hed his trunk forward with his h a n d s .
l1ex i n g the knees a nd h i ps and not the lumbar
h ad to use two pil lows
sp i n e . whi l e supporting the u p per body on a
I f he slep t on h i s s i d e , he
co u n ter : the return to the u pri g h t positi on shou ld
between his knees.
b e achi eved by making a consci ous effort to con
• Visit
tr act t h e g l u te u s maximus musc les
2
• performing h ip abd u c tion w i th the hip and knee
Reassessment
extended while side ly in g : in ad d i tion performing .
Steven r etu r ned in 2 weeks for assess ment of h i s progress a n d progression of h i s programme. A t th at time, he d i d not have any p a i n in h is r i gh t h i p but d id develop p a i n in his l e ft groin after walk i n g for more than 3 0 m i n u tes. His p a i n did not reach the previous leve l of 8 -9 / 1 0 , bu t only bec a me 2 - 3 / 1 0 a fter s t a nd i n g o r walking. A t the time o f his v isit. he d i d not have a ny p a i n in either groi n . Test res ults were as follows: • hip Oexor length : without hip abduction the righ t
hip ad duction w i t h the bo ttom lower ex t r e mi ty • i nstr uctions in waU<ing to take a slightly longer
stride. using contrac tion of the gl ute a l muscles of the stance l e g at heel stril<e : the push-ofr should
b egi n at the end of mid-stance phase • walking s h o u l d be progressively i nc reased t o 5 km, prov ided no pain developed i n his groin • ot her exercises were to be continued and i n cre ased
to 1 0- 1 5 re pe t i tio n s twice d ai ly. Steve n 's return appoi ntment was set for 2 weeks.
and left h i p s extended to w i thin 1 0 d eg rees of com p l ete ex tensi o n • pass ive hip flexi o n was 1 2 5 degrees without symp
• Visit 3
toms o n t he ri g h t side a n d 1 1 5 de g rees with slight
Steven repor ted co ntin u ed improvement in his con d i
pain o n the left
tion. He was able to walk for 5 km but did develo p sl i ght
• hip l1exion with lateral rotation of the
h i p and
p oste rior ly d ir e cted pre s su r e i n t o t h e h i p j o i n t : .
p ai n in his left groin about halfway. The pain gradually increased during the remai nder of the walk : h owever
symptom -free hip flexion ran ge improved by 5
it subsided almost immedi a tely u pon cessation. Steven
degrees
was pain-free with all of hi s exercises. incl u d i n g active
• pos ter i or g l u teus medius manual m u scle test: 4 / 5 b il a tera l ly
and passive hip Oex i o n to 1 3 5 degrees
.
Active an d
passive strai ght leg raising was to 80 degrees. with -
• gluteus maximus manual muscle test: 4 / 5 bilaterally
both the rig h t and left greater trochanters main tained
• iliopsoas m a n u a l muscle test: 4 - / 5 with some pain
in a constant position . In the prone posi tion, the
• quadruped: Steven could rock back to 1 2 5 deg rees
greater trochanter also ma i nta in ed a constant posit i on
of hip Oex i o n w itho u t pain and wit ho u t a ten
d ur i n g h ip extensio n . All muscles tested 5 / 5 except for
dency to l1 ex his l u mbar spi ne
the il iopsoas, which tested 4 + / 5 b il aterally.
• kn ee extens i o n in s i tti ng : no lo n ge r associated
Steven was told he could start alter n a tely r un
with hip medi a l rotation a n d was full r a n ge of
n in g for 1 m i n u te and wal k i n g for 1 mi n u te for a total
mo t i o n .
of 30 m i n u te s every other d ay fo r 1 week. If he
The assess ment i n d i c ated t h a t St e ven h a d m a de good progress, as evident by the m arked decrease in the severi ty a n d freq u ency of his pai n . This is the fir s t peri od i n which he had an i mprovement in his condi
re m a i ned p ain-free he could increase the r u n n i ng to .
2 m i nu tes . He was asked to call me i n 3 weeks to
report his prog ress
.
When Steven c alled 3 weeks la ter. he said he was able to r u n for a to tal of 5 km every other da y He was .
tion i n the past 1 8 months.
given perm iSSion to return to karate so long as he mainta in ed his exercise p rog ramme and perfo r m ed
P rogram m e mod ificati o n
tbe exercises a fter the karate session . Steve n ' s mother cal led a month later a n d indicated
T he programme was then mod i fie d :
that her son was doing very well a n d had resumed
• i ncreasi n g the r e sista nce for the hip l a teral rotator exerc i ses
his k a r ate without experiencing symptoms.
Copyrighted Material
a
recu r r e nce of his
1 8 A D O LESCE N T H I P PA I N
R EAS O N I N G D I S C U S S I O N A N D C L I N I CA L R E AS O N I N G C O M M E N TA RY
II
Did you ex pect such rapid and complete
devel opment and ins truction in therapeutic exerc ises.
recove ry given the chronicity of the disorder
There i s a prevail i n g belief that strengthening exer
and failure of previous medical inte rvention?
cises are the key to tissue recovery, but t h a t is o n ly true if the u nderly i n g movement p attern a n d muscle participation i s precise,
• Clinician's answer
Painfu l conditi o n s o f the hip are o f par ticu l a r
Based on my ex perience w i th other patients w i th t h i s syndrome, I d i d expect a g o o d recovery a n d p a i n e l i m i n ation w i t h i n 4 wee k s , The p a t i e n t ' s c l i n i c a l fi n d i n gs were so consiste n t w i t h those of the syndrome, that I d id expect the c o n d i tion to reso l ve q u ickly, My m aj o r concern w a s t h a t beca u se t h e pati e n t l ived s o far away a n d return v i s i ts to phys ic a l therapy could n o t be frequent, h i s correct performance of the exerc i ses was esse n t i a l . I u s u a l ly do n o t see patients more t h a n
o n c e a wee k , b u t k n e w t h a t t h i s type o f frequency for appoi ntments over an extended period wo u l d n o t be poss i b le , The patie n t ' s motivation and participation were e n h a nced by learning about the obvious muscle a nd moveme n t imp a i rm e n ts th at were prese n t , how his symptoms could be c h a n ged, and th at the condi tion was known to me, He had specifi c performance problems to correct, which aided his motivation and u n derstand i n g of wh at was to be a c h ieved , The oppor t u n i ty to be ' i n c h arge ' o f h i s condition had been absent d u ring the past year. He had been u n a b l e t o do a nyth i n g but wait and h o p e , The p atien t was bright. was an athlete, k n ew his body and w a n ted to be active. The comb i n a t ion of all these factors cer tainly provided optimal conditions for the necessary
i n terest to me, b e c a u s e medi c a l i n terve n t i o n s h ave been limited . Surgical treatme n t has been for h ip j o i n t repl acement, w h i c h o f course i s l i m i ted to t h e e lderly when clear s i g n s o f degeneration are presen t . More recently, labra l tears h ave been iden t i fied in yo u n ger i n d ivid u a l s a n d n o w s u rge o n s are debrid i n g ( re p a ir i n g t h i s ) t hese te a r s , b e l ieving t h i s w i l l add ress the patient's pa i n . The question has to be aske d , w h a t c a used the tear? Debrid ing the t e a r w i t ho u t add ress ing the moveme n t impairmen ts th a t I bel ieve c a u s e the tear i s o nly p a r ti a l tre atment. U n for t u n a te ly, s u r geo n s are n o t aware of the kinesiological movement i m p a i rments o r that the rapists can e ffec tively treat these probl e m s ; therefore, too few p atien t s with these problems are referred to therapists . Med ic a l interve n tion for musculoskele tal problems is l im i ted to medi cation that reduces i n flamma tio n a nd pain o r to s u rgery for d a m aged tiss u e s . Neither o f these treat ments addresses the c auses of mec h anical mu scu loskele tal p a i n problems. That i s why, as physical therap ists , we m u s t describe t h e syndromes req u i r i n g o ur interve n t i o n , so that patients , referral sources a n d therapists become aware o f o u r professional expertise in diagnosis and treatmen t o f these conditions .
participation by the patient. I bel ieve that the rate a n d ex tent o f the patie n t ' s
recovery supports the bel ief t h a t prese nce o f the
• C l i n i cal
i m pai red movement pattern was the cause of the
With a clear link of man agement to examination
tissue irritation. I believe that, all too o ften, therapists assume that they have to provide p a i n-relieving mod a l i ties or 'calm tissues dow n ' before beginn i n g exercises. I consider t h i s a misd irec t i o n , beca u se my ex perience has been t h a t correcting the movemen t impa irment a nd t he c o n tri buting fac tors i s necessary to allev iate the pa i n . T h i s does not mean that acu te i n j u ries s h o u ld
not
be treated
with appropriate
mod a l i ties , but certa i n ly not chronic conditions that h ave had s u i table time [or tissue repair. This syn drome also illustrates the critical importance o f preci sion
in
kinesiological
observation
and
in
the
reaso n i n g commentary
fi n d i n g s , the clinicia n ' s collaborative reaso ning stands out thro u g h her i nvolvemen t of the pati e n t
i n self- m a n a gemen t . P a tient l e a r n i n g ( i . e , altered u nderst a n d i n g / beliefs , feelings, b e h av io u r s a n d neuro m u scular co ntrol or m o tor pro g ra m mes) i s t h e p r i m a r y outcome s o u g ht i n t h e coll aborative reaso n i n g appro ach .
Rather than being passive
recipients of health care, and m a n u a l therapy in
p a rticu l a r,
patients
a re
taught,
cou nselled
and coac hed so a s to enable them to construct
new perspective a n d , as for Steve n ,
Copyrighted Material
a
a
new m o to r
CLIN I CA L R EASON ING IN ACTION : CASE STUD IES FROM EXPERT MANUA L TH ERAPISTS
progra mme; these hopefully a l low them to m a i n t a i n
reasoning skills t h a t u n d erlie s liccessfu l a t t a i nment
the i m p roveme n t a c h ieved a n d to m i n i mize t h e risk
of this
of recu rrence. This level o f l e a r n i n g and respon s i b i l
i n g a n d motor c o n t rol theory. p ro fes s i o n a l craft
ity
for self-manage me n t requ ires shared dec i s ion
ma king. Exerc ises need and progressed from
a
to be u n derst.ood . a ccepted co g n itive awareness of the
outcome. Proposi t io n a l kn owledge o f learn
knowled ge. skills
in
te a c h i n g and motor retra i n i n g
stra t egies . a n d person a l k n owledge from l i fe experi
en c e s to establish rapport with a n d
cont ro l req u ired to au tomatic functiona l execu t i o n .
patien t represent
A
cess w i t h complex c l i n ic a l
w r i l.t e n
can
text
of
selected exerc ises.
as
prov ided here.
some
motivate
of t he prereq u isit"es for
t he S ll C
presentations.
never fu l ly capture the teaching and collabora tive
• Refe rences Adkins.
S.B.
,m d F i g l er. R . A .
( 2 00 0 ) . H i p
p a i n i n a t h l e t e s . A m erican Fa m i ly
6 1 . 2 10 9-2 1 1 8 . Clemen t . LJ . B . . A m m a n n . W. . T'l U n ton. f. E. el a l . ( J 99 n Exercise- i n d uced s t ress i n j u r i e s t o t h e fe m u r. I n te r n a t i o n a l f o u rn a l o f S p o r ts Ivl e d ic i n e . 1 4 . P hy s i c i a n .
T L. ( 1 9 9 8 ) . T h e Hip
Ha n d bo o k , O x ford : B u t t erwor t h
He i n ema n n . Florence, T. . Pa n d y a . S . . K in g . W, et a l . ( J 9 9 2 ) . l n t ra r a te r rel i a b i l lty o f m a n u a l m u s c l e test ( M ed ica l Researc h C o u n c i l
S c a l e ) grades
i n D u c h c n ne ' s m u sc u l a r
dys t rophy. P hys i ca l Thera py. 7 2 .
11 5- 1 2 2 , Gelberma n , R . a n d H e kh a r. S ,
a n d foi n t S u rgery. 6 9 13 . 7 5- 7 9 ,
c.e,
T.c, ( 2 0 0 0 ) , i n Phys i c a l
a n d S nyder.
D i ffere o li a l D i a g nosis
T hera py. Lo n d o n : S a u nders,
R , E. ( 1 9 9 6 ) , D i ffere nti a l d i a g n os i s w i t h seri olls p a t h o l og y : il Cilse report. Physic a l
Jo n e s .
D,L.
I h e Lower L i m b s a nd
O r t hoped i c s
i n Ch i l d re n , Cl i n ic a l Re l a ted Researc h ,
a n d Erh a r d .
T hera py. 7 n , S 8 9 -S 9 0 ,
Meyers,
W, C . .
L o h n e s . f, H , a n d M a n d lcb a u m ,
B . l� ,
( 2 0 0 0 ) . M a n a gement o f severe l ower a bd o m i n a l or i n g u i n a l
pain
in
h igh-perfo r m il n c e at h l e tes, A me r i c a n
28. 2-8 , O · Ka ne. J , w. ( 1 9 9 9 ) . A n terior h ip pa in , A me r ic a n Fam i ly PhYSicia n , 6 0 . j o u r n a l o f Sports Med icine.
Po l g l a s e .
j o u rn a l or H o n e a n d J o i n t S u rgery, 6 7 1\ . 3 9-4 7 ,
S t r i c e v i c . M , V. . Pa e i , i\Il, l\ . . O k a za k i . T. a n d S wa i n . f3 . K . ( 1 9 8 l ) , K a ra te : h i stori c a l pen; pectivc ,ll1d i n j u ri es s u s t a i n ed in n a t i o n a l ,l Ilei i n ter n a t i o n a l 01' Spor t s M e d i c i n e . I I . 3 2 0- 3 1 4 , Ta y l or. D , C . . Meyers . V\l. e " M oy l a n . f , A " Lo h n e s . j " Ba ssett . E I-l . a n d C a r rett . W E , j , ( 1 9 9 1 ) , A bclO ini n a l m u sc u l a t u re
abnon n <l l i t i e s oS a c a use of g ro i n pa i n
i n a t h letes. I n g u i n a l hern i a s a n d p u b a l gi a , A m e r i c a n j ou rn a l o r S p o r ts
for d e b i l i tati n g c h ronic groin p a i n i n a t h l e tes, Med i c a l J o u r n a l of A u s t r a l i a . 1 5 5 , 6 7 4-6 7 7 ,
S a hrma n n , S , A , ( 2 0 ( H ) , D i a g n o s i s
a nd
I m p a i rment
S y n d ro m e s , Lo n d o n : Mosby,
Stahel i , 1 . . . Corbe t t . M . . Wy s s . e , a nd K i n g . H, ( 1 9 8 5 ) . Lowe r-ex t re m i ty
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Sa h rmann. S . . Norto n . B , p bysica l cx a m i n a t ion i tems u sed for c l ass i fic a t i on of p a ti e n ts w i t h low back p a i n , P hYS i ca l T h e r a py. 7 8 . 9 7 9-9 8 8 ,
va n
Fann e r. K , C , ( 1 9 9 1 ) , I n g u i n aJ s u r gery
of M ov em e n t
journa1
Med i c i n e . 1 9 . 2 3 9-2 4 2 ,
A , L . . Fryd m a n . C , M , a n d
Treatme n t
rot <l t i o l l a l p ro b l e m s i n c h i l d ren ,
t o u r n a m e n t c o m pet i t i o n s , A m e r i c a n
Po lely. D Y . C a r rett. W, Kj . .
1 6 8 7- 1 6 9 6 , ( 1987),
Femor a l a n teversion , J u u r n a l o f B o n e Goodm a n .
A n g u l a r a n d 'I'ors i o n a l LJe fo nn i t ics o f
1 7 6 . 1 3 6- 1 4 7 ,
3 4 7- 3 5 1 . Fagerso n .
Kend a l l . F. . M cCrea ry, 1':, and l)rov'lI1 cc. l' ( 1 9 9 3 ) , M u sc l es Tcs t i n g a n d F u n c t i o n , Lon d o n : Wil l i a m s & W i l k i n s , K l i n g , T a n d l-l e n s i n gcr. R . ( 1 9 H 3 ) ,
D il l e n .
L. .
e t a l . ( 1 9 9 8 ) , Rel i a b i l i ty o f
Wi l kerso n . L, A , ( 1 9 9 7 ) , M a r t i a l a r t s i n j u ries. J o u r n a l of
the
A m e r ic a n
O s teop<l t h i c Assoc i a ti o n . 9 7 .
2 2 1 -2 2 6 ,
A software p rogram m e r
an d s p o rts m an with l ow bac k pai n an d sc i at i c a Tom Arild Torstensen
� O lav is
S U BJ E C T I V E E XA M I N AT I O N a
4 8 -yea r-o l d mar ried ma le w it" h two sons, a ge d
2 1 a n d 2 4 , from
work. He a lso res um ed other activities su ch as soccer,
prior m a r riage. He is of ave r a ge
j oggin g a n d other sports. Howeve r, after thi s episod e o f
h e i g h t lor h is wei g h t . bein g ] h4 cm ta l l and we igh i n g
sciatic a , h e never fu Ily rec o vered and co n ti n u e d t o
7 5 k g . O lav i s a n o n -s mo ker a n d h a s
n orm a l i n t a ke o f
expe r i e n ce r e l ap s es , w i t h b ac k pa i n , b uttock pain a n d
keen s o ccer p l ayer and
some leg p a i n , mostly o n h i s left s i d e b u t s o m e time s also
is s ti ll on h i s com pany 's wccer te a m . His s o n s a l s o p a r
o n h is r i g h t s id e . He repor ted that o v e r the l a s t few
conte n d e r far the n ati o n a l
years he c o u ld ' fee\ ' his back most d ay s , and he always
cross-country ski tea m . When possi b le, Olav l ikes to
h ad to be c arefu l with what he was d o ing . Except for painkillers a n d non-steroidal a n ti-i n f1 a mm atory d r ugs (NSAIDs ) , he had never had a ny lTeatment for h i s back
a
alco h o l . [ n h i s free l i me. he is t i c i p a te in sport. w i t h one
a
a
a
j o i n his sons in t he i r spo rts . H owever, h i s p hy s ic al activ i ty level h as decreased sign i fican tly over the l a s t few yea rs . bo t h fro m the pre ss ure s of h is work a nd bec a u se
problem. Ly ing down and r e s ting the back eased the
of h i s rec u rre n t back problems.
symptoms, wh i le sitting and being too physically active
s e n i or co m p u te r softwa re
increased the s y mp t o m s . His tw i n b r o t her had h a d low
p r o g r a mmer w i th an i n ter natio n a l c o m p c my. At the
back s urgery because of sci atica and t wo uncl es had
O l av e n j oys h is work as
a
time o f his i n i ti a l c o n s u lta tion he was hav i n g to trave l
also u nd ergone su rgery for l o w back pr o b l ems . The
lo t between Oslo a n d C o pe n h a gen , w h ich is
opera tions were i n i t i a lly su ccessful. with an Lmprove
q u i te
a
a ppr ox i m a te l y 1 hour by a i r. His work is ve ry stressfu l w i t h c o n s t a n t pres s u re t o meet company deadl i n e s . H e h as a ty pic a l compu ter workplace a n d u se s b o t h a des ktop pers o n a l computer a n d a l a pt o p. D u ri n g a ty pi c a l wo r k i n g d a y, he s p e nd s most of h i s t i m e s i tt i n g i n fr o n t o f h i s c o m p uter or i n meeti n g s .
men t in sy m pt o m s and fu nction, but a l l three h a ve had repea ted r e lapses wi t h back pain and s o me leg pain. His twin brother was working fu ll-time r un n i ng a tr avel agency a nd h is u ncles also retur n ed to fu l l- t i me work before they retired d u e to a ge.
P resent m e d i cal h i story Past m e d i c al h i story
Olav was ' r efer red ' to p hysio therapy by a co-worke r
Ten years ago, Olav ex per i e n ced acute back p a i n when
who had been a p a ti e n t of mine fo r some time. He
l ifti ng
c o mp u ter. He was orf work for 1 m o n th with
waU(ed in to the tre at me nt room with a s l i g h tly flexed
back p a in, which develo ped i nto classic Sl sciatica, a n d
p o s tu re a nd us i ng short s teps . W h iJ e w a i ti n g o u tside,
a
was bedrid den most of the time 'eati n g ' pa i nk i l l e rs .
h e preferred n o t to sit b u t v aried his posture between
VVhen s y mpt o ms were reso l v i n g , he started s l ow l y
s ta n d i n g sti l l and wa lking. He told m e t lla t his back
got back to
p a i n now was much worse than in the past and t h a t
i ncreas i n g h is a c t i v i ty level . u n ti l he fmal ly
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•
requ ired him to s i t . He was also afraid th a t he wou ld not be able to travel by air because of his d i fficulty with prolonged s i tting. Olav had now been on s i ck leave for 2 weeks,
a l t hough d uri n g the last week he had been at
work for short period s to catch up with his proj ects . He was also frustrated beca use he now re a l ized that the symptoms recurred fa irly qu ickly whenever he started to load his back during ordi nary da i l y activities. He expressed concern that he mi ght end up ly i n g in bed for a month or two as he d i d 1 0 years ago. The treat ment so far had consisted of pain kil l ers o n ly (NSAIDs ) . easing t h e symptoms sli g h t ly. Because of the i ncreased sy mptoms. he had to lie down during the middle of the day. His symptoms cha n ged with biomech anica l factors such as loading of the spine. as well as w ith positions of the spine. such as
flex ion versus extension. When he was in a weight bearin g position or a sitting position . the pain i n his back and the lower extremity increased. Wh e n ly ing dow n , the p a i n genera lly decreased a n d after ly ing fo r a couple of hours he co u ld be close to bein g pai n-free . His pain was 8-9 / 1 0 in a standing or s i tting pos i tion and 2 - 3 / 1 0 i n a lying positio n . Walking could relieve his sympto ms for a short while. but walld n g fo r lo nger
than 30 minutes increased the symptoms. During a typ ical day. there were nearly no symptoms when wak ing up in the morning. On getting o u t of bed . he was a Fig. 1 9. 1
Bod y chart i l l ustrating pati en t's sy mptoms.
little bit stiff in the back. but the p a in was bas ically
go n e . T h e stilTness dis appeared after moving aro und for
1 0-20 minutes. When weight bearing during the day, d u ring the last 2 weeks he had been regularly ly i n g
the pain in the b a ck and leg reappeared and he had to
d ow n t o e a s e the b a c k a n d leg pain ( F i g . 1 9 . 1 ) . H e felt
lie down in the middle of the day to ease the symptoms.
h i s most recent rel apse 3 weeks ago was prob ably the
In the after noon, the p a i n was quite marked if he had
res ult o f a lot of lifti n g when moving some fu rni ture.
pushed himself e arlier by doing a lot o f s i tting and
Ove r the next 4 8 hours the pain h ad i ncrea sed slowly,
standi ng. A rter a good night's s leep h e fel t fine. the next
u n t i l it was u nbearable a n d he had to lie dow n . S itting
mor n i n g bein g again bas ically symptom free. Going to
was not possible a n d h e was now qu i te fr u s tra ted
the toilet was prob lematic, especia l ly when havi ng to
because he wa s busy at work a n d some of his work
' p ush ' . Also coughing i n creased the symptoms.
� IJ -
REASO N I N G D I S C U S S I O N A N D C L I N I CA L REASO N I N G C O M M E N TA RY
Please h igh l ight what yo u c o n s i d e red to be
• C l i n i cian's answe r 70-8 0% of the i n formation I need to
the key i n formati on that had come out at th i s
I tend to get
stage o f the i n itial exa m i nati o n a n d bri efly
design a treatment programme from most patients
c o m m e n t on yo u r hypoth e ses regard i n g th i s
through the c o nversation ( p a s t a n d present medic a l
info r mati o n .
history ) . T h i s applies especially fo r patients w i t h
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1 9 A SO FTWA R E P RO G RA M M E R A N D S P O RT S M A N W I T H LOW BACK PA I N A N D SCIATICA
w h i c h rel ieves t h e sympto m s . This is typical o f a
long- lasting chronic pain . Tills view is supported by a research study showi n g that for new patients 7 6 % of
possible i n tl a mmatory process , for example as c a n
diagno ses was based on patient history, "vith 1 2 % based
o c c u r with a disorder o f t h e rVD.
on physical examination and 1 1 % on laboratory inves
The m a i n symptom is morn ing stiffn ess
Pattern 3 .
with p a i n , which d ecreases as the patient starts to
tigation (Hamton et al . , 1 9 7 5 ; Pe terson et al . , 1 9 9 2 ) . active
move . However, after weight beari n g for a couple of
coper, being able to deal "vith his problems in a he a l t hy
hours the symptoms reappe ar and may even start
From taUdn g with Olav I fe lt that h e was
an
way. It was a good sign that for m a ny years he had dealt
to i ncrease. Now the patient o ften has to lie down to
with his back prob lem h imself rather than run from
rest the b ack in order to ease the symptoms . For the
one health profess ional to a n o ther. He was not afraid of
rest o f
using h i s back even though he had back pain, and he
without leg p a i n , but is able to keep going by having
was not a fraid of testing out and pushing himself with
short rest periods i n a supine posi tio n . Th is patient
the d ay the p atien t has back pain, with or
his recurre n t back problem. However, he probably
has a pattern o f symptoms associ a ted with impair
needed some su pport regard in g ' phasing ' , particu larly
ment o f both the elisc and the facet j o i n t s . but t he
in rel ation to how much he shou l d push himself. In
d isc is pro b a b ly the main organic structu re from
addition to this, he enj oyed h is work and tried witill n
which the symptoms are comi n g .
h i s capability to get back to work as quickly as possible. So psych osocial issues, such as ne gative fear-avoidance beliefs or believin g that physica l activity and going back to work would be dangerous, were not l ikely to feature.
He was coping in a normal way to his pain experience. I consi dered that I was deali n g with a patient who
was now su ffering from q uite a lot of pain c a u sed by straighliorward tissue pathology : a n infla mmatory
process from a possi b le prolapsed intervertebral d isc
(IVOl causi n g sciatic a . The history supported this view: s i tting i ncreasing the symptoms, lying down easing the symptoms, fee ling well in the morning but both b ack pain a nd leg pain increasi n g as the day prog ressed a nd the back was loaded in weight-bearing positions. He also had a recognizable 24-hour symptom pattern . I have fou n d there are three d ifferen t categories of
2 4-hour symptom pattern, which are very useful as a pred ictor for outcome and for respons iveness to exer cise therapy (PaugJi, personal communication , 1 9 8 6 ) : Pa ttern 1 .
The patient wakes u p i n the morn i n g
because of p a i n a n d mor n i n g stiffness. T h is eases with riSing and starting to move a n d the patient is basically symptom free duri n g the day. The more the patient moves the be tter the back gets. The s igns a nd symptoms are typic a l ly j O i n t related , s i m i lar to those associated w i t h an ar thri tic h i p j O i n t . M o s t of t h ese p atients respond very positively to ac tive graded exercise therapy l ike the medical exerc ise therapy ( MET) appro a c h . Patte rn 2 .
T h e p a t i e n t is c l ose to symptom free
in the mor n i n g , b u t the p a i n and s t i ffness retu r n as
Patterns 2 a nd 3 usually tal<e longer t o treat a n d are generally more complicated/eli[ficult to manage. Olav has a typical pattern 2 presentation. where both the dis tribution and the pattern of pain indicate a prolapsed disc with
an
inl1amed sciati c nerve. This is especially
supported by the fact that sitting was
difficult and
pain ful. It is one o f Olav's major concerns because his job requires rum to sit for long periods o f time, which results i o a pain in both the back and the leg. His work situation with constant deadlines m akes it diffic ult to avoid si tting and yet he has to tal<e time off work to lie supine at home. I note that I will need to advise O lav that he will need to change pOSition at work as much as pos sible, avoiding positions that are reaUy painful and mal<e him worse. If necessary, he must also try to find time to l ie do"vn for short periods at work. When at home in the evening or during weekends he must again try to stay in comfor table positions, avoicUng the 'pain ' . Tills means that he must stay in a comfortable, close to pain-free, supine posilion u ntil he is experiencing symptom con trol and is able to sit for l o nger periods . This approach is very important d uring the first early stage of the treat ment. I also
think that MET will be appropriate to begin
to load the body and the back in a controlled env iron ment using comfor table starting positions, such as lyin g a n d stancUng deloaded positions. I f t h i s proves effective in decreasing his symptoms, the programme cou ld then
be progressed to exercises in sitting and standing to con dition his tolerance to sp in al loading further.
IEJ
Could you elaborate on this i m pression that Olav was an 'active co per' and was l i kely to be
the patie n t moves around and bears weight. Du ring
suffering from genuine tissue pathology? That is,
the day, the patient has to rest i n a supine positi o n .
if this hypothesis is to be supported, what would
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CLINICAL REASONING IN ACTION : CA S E STU DIE S FROM EXPERT MANUA L THERAPISTS
I
the tissue
• Cl i n i c ian's answer Coping h as been d e scr i b e d as !\n i n d iv i d u a l 's effo r ts to
d e m a n d s ( co n d i t io n s of h a r m , threat, or chal
master
l e n ge) t h a t are a p p rais e d (or p e rc e iv ed ) a s excee d i n g or tax i n g his or her resou rces ' ( Mo n a t
1 9 9 1 , p.
and L a za r u s
,
5).
S tress , coping and p hy sical ill ness can be cl osely l i nked . Holroyd and Lazarus ( 1 9 8 2 ) suggest three main ways i n wh ich s tress mig h t lead to soma t ic i l l ness: • by
d is r u p t i n g
tissue
fu nction
t hr o u g h
make a straightforward d i a gnosi s by recog n izin g a t fa u lt w h ic h is causing the symptoms. This p rese n t a t i o n is somewhere be twee n Type 11. types r a n d III ; th ere is c lose to normal pai n beh av i o u r, but it is d i ffi c u l t to re la te signs and sy mp toms to
you expect from your physical exa m i n ation and how does thi s issue i nfl uence your management?
neu ro
directly to
a
t i ss u e at fa u l t. A ty pe II p a ti e n t presen
tation may l e a n more towa rds type I or ty pe IfI. de p e n d i n g o n the un ique c h aracteristics o f their presentatio n : this can c h a nge over time and wi th
treatment. A n ex a m p l e of this is the p at i en t who star ts w i t h
a
local p ro b l e m ( e . g . lum bar p ai n with
sciati c a ) t h a t changes t o
a
mo re di ffuse pr esen ta t i o n
where some signs can be r e p r od u c ed a nd ot hers cannot. The pain p a ttern may a l so h ave c h a nged
h u meral i n lluences under s tress ( e . g . h orm on e s
over t i me to l a r ge r a n atom ical are as in the
c a u s i n g i n c r e ase d he a r t b e a t , tre m b l i n g )
and
• e n g a g i n g in copi ng activities t h a t a re
d a m a g i n g to
h e a l th ( e . g . a p r ess ure d style of l i fe , type A b e h av iour) : t a k ing m i n i m a l rest. poor d i e t , he av y use o f
tru nk
lower extremities , n o t t y p ica l for str a i g ht
forward sc ia tica . The maj ority of patients i n my
p r ac tic e fa ll i n to t h is c atego ry. Type Ill .
T h is
a b n o rm a l
presen tation h a s
pain
b e havio u r w i t h m aj o r psyc hosocial stressors . n o n
to bacco or alcohol • m i n i m izing t he sig n i fI c a n c e of symptoms or fa i l i n g
s pec i fI c / d if fu s e p a i n , a n d t h e signs and sym ptoms
d i [ficu l t to re prod uce
to co m p ly with trea tment as a result of psyc ho
are non -reprod uc i b le. I t is
log i c a l a nd/or sociolog i c a l factor s .
symptoms conSisten tly w h e n repeat i n g te s ts a n d ,
In t h i s con tex t a n active co per is a p e r so n w h o is able ,
to deal
with s tr es s i n a po s i t ive way, wh o ha n d les the
s tress and ri nd s posi tive, c o n s t r u c t i ve solutions to t h e s t ressor( s ) . As
a c l i n ici a n , I often n n d t h a t p a t i e n ts with n o r
m a l posi tive ac tive copi n g s tra tegies most o ften pre se n t s u ffe r i n g [rom genuine t i ss u e pat ho l o gy a nd w i th normal p a i n beh aviour, which wa s t he c ase for O l av. I also hy p ot hes iz e d at this e a r ly s tage of t h e examin ation t h a t Olav's p r ese n ta t i o n was co n s i s te n t with the source of his symp toms as a r ecog n i z a bl e p atho l ogy in the muscu loske l e t a l syste m , T h i s would n eed to be tested fu r ther in t h e p hy s ica l ex a m i n ation and t h e re s p o n s e to treatmen t . I n t h i s c o n t e x t I h ave fou nd i t ,
us e fu l to b roa d ly c l a ssi fy p a t i e n t prese ntatio n s i nto three c a tegories ( ty p e 1 , type II and ty p e III p resenta ti o n s) with respect to the symptoms a n d p a i n b e h av iour; t h i s assists me i n d e te r m i n in g the appropri ate approach to m an ag em e n t (De C lerck , 1 9 9 8 , 1 99 9 ; Torst e n s e n and D e Clerk . 2 0 0 1 ) . Type 1.
on t h e pain dr aw i n g t h e patien t m ay m a r k
the pain
o u t s i de th e bo dy o r o ve r l arg e anatomical a reas that do not co i n c i d e wi th ' norma l ' pain p a tt e r ns re l a ted to dermatomes, myotomes a nd sclero tomes .
Thro u g h t h e course of m a n agement, a p at i e n t can stay in the same p r e sen t a t i o n or can move from ty p e HI to type II or from ty p e II t o type 1. In my c l inic, I
p ro b a b ly see ap p r ox i m a t e ly 2 0-2 5 % ty p e
I. 1 0-1 5 %
type III and 6 0- 7 0 % ty p e I I p re s e n t a ti o n s A ty p e I p r e s e n t a t ion is u s u aJJy easy a n d s tr a i g h t fo rward to t r ea t u s i n g well-known methods i n m a n u a l thera p y. Here p a in can be a gu ide t o treatmen t. u s i n g
a
treatment ap p r o a c h The trea tment is a i med p r i m a ri ly at p hysiolo g i c a l e ffe c ts ( loc a l l y ) symptom control . and promoting h e a l i n g and recov
p a i n con ti n ge n t
.
,
ery. Signs a nd sy mptoms can guide the treatment and
d i ffe ren t m a n u al t h e ra py a p p roac h es may be e ffe c ti ve. This patien t p res e n t a t i o n ca te gory is ty p i c a l ly covered
by the
trad itional c o u rs e s and
s e mi n a rs in ma n u a l
ther apy a nd i s d esc ri be d i n cli nical textbooks. The c l in
T h i s group h ave normal pain behav iour,
i d e n tifI a b l e tissues at fa ult. loc al or r ecog n iza ble p a in
ical pr e se n t at i o n is easily reco g n i z ed by c l i n icia n s . For a type II pr e se n ta tio n ,
I would i n i ti a lly treat t he
p a tterns and reprodUCible si g n s . The p a i n d istribu
p atie n t similar t o a ty pe ill p re se n ta ti o n Then, depend
tion i s u s u a Uy i n a wel l k now n pa tte r n and signs
ing on th e ir response over the next few sessions, the
-
.
and symptoms are consisten tly r ep ro d uce d by clin
tTeatme n t will either cha nge to
ical tests . For a ty p e I presentati o n , i t may be p os s i b le
continue with a ty pe III a pp ro a ch . Afte r d e a lin g with
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a
ty pe I a p proach or
1 9 A SO FTWA R E P RO G R A M M E R A N D S P O RTS M A N W I T H LOW B ACK PA I N A N D SCIATICA
psychological issues lU<e p ain behaviour, it may become
w i th p ai n , a s w i th a n ope rant cog n i ti v e-beh av i ou ra l
clearer for the the rapist which presen t atio n is d omi n ant .
approach . F u r th er, s i mpl e g rading o f exercises w ill
A ty pe m prese n t at io n i s m or e d i fficu l t to treat
e n ab le h is trea tmen t to be close to p a i n - free a nyway,
i n t hat trea t m e n t is p ri m ari l y a i med a t c h a n ging
a n ex perie n ce t hat is positive ly motiva ting for patie nts
behaviour ( g l o b al ly ) , foc u ss i n g o n sl ow, prog ressive
with p a i n a nd dec reased fu nctio n . M os t o f the exer
fu nc t iona l recovery with a clear u nd erstanding of ma l
cis e s chosen for O l av were sem i - gl o b a l a nd g lo b a l . In
ad a ptive p a i n . For a type III p resenta ti on , p ai n may be
the early p b a se, the exerc ises chosen foc ussed on sta
a n un reliab le g u ide for treatment; therefore , a q uo t a
bili ty, u s i n g pri m aril y semi- global a n d l oca l exerc i ses .
based exerc ise programme may be used. In a d d i tion ,
cognitive--be h av iour te c h n i q ues ( K ee fe
et a I . , 1 9 9 2 , 1 9 9 6) , with emp h as is o n c l ear realistic go als using appropriate phasing s k i l l s (Bassett a n d PetTie, 1 9 9 9 :
La te r, when the t r ea t me n t pro g ressed , more glo b a l exerc ises were i n tro d u ced . I also knew from experience that if Ola v was able to avoid a ny f1are - ups a nd slow ly increase h i s tolerance fo r loading through a gra d ed exercise programme, he
Waya n d a e t a l . , 1 9 9 8 ) . For a ty pe III prese n t a t i o n , a
s ho u ld recover within 2 to 3 months. To re ac h t h is
non-pain co n ti n gen t a p proach s h o u l d be used, or a
go a l . I fel t it was of the utmost importa nce that he u nd e rs too d what "va s go i n g on and what type of p a in h e had a nd where the pain was comin g from. If he a p preCi ated this in formation, it wou ld be easier to mod i fy, in a very structu red way, his da ily activities so th a t
the treatment shou ld i nc lude intensive education using
so-cal led time con t in ge n t a pp ro a c h , w h ere t h e p at i en t ' s pain is n ot used as the gu ide for trea tme n t . F u r t h e r,
trad itional man u a l t hera py methods , where the a im
is to decrease p a i n , m ay make the pat ie nt worse by
he ac hieve d symptom contro l . Because his history ind i
i nc reasi n g the i l lness/ p a i n behaviour. T h i s classifi c a tion of patient presen tati on s in re l a
cated a fa irly stra igh t forwa rd orga nic d y s fu n ction ,
t i o n to t h e i r p a i n behaviour a lso has i m p l icatio n s fo r
with a possib le prolapsed d isc a n d an in f1a med S l nerve root, I fe l t i t was i mportant to expla in that for now he
determ i n i n g the type of exercise, the g rad i n g a nd d osage of exerci ses , t he l o ad i n g of e ach exerc ise a nd if
h ad to try to avoid biomechanical pOSitions that gave or
t h e exercises s h o u l d h a ve a globa l . semi - g lo b a l o r
increa sed h is pain .
loc a l focus t o norm a l ize fu nction :
comfo r ta bl e exercises to c hoose, comfortable starting
• globa l exercises i nvo l ve u s i n g exerc ise equipment such as a rowi n g m a c h i n e , step p i n g m a c h i n e , sta tionary bU(e. treadmi l l , w h i c h wor k t h e who l e bod y • semi-global exercises are exercises using the MET pul leys or l'ree exe rc ises worki ng against gravity, where o n ly
a par t of the muscu loskeletal system is activated
• local exercises are exercises using the MET p u ll eys and
other MET eq u i pm e n t where the exercises are even more local ized to a few segmen ts of the back: a typ ical local exercise wou ld be to try to activate transver sus abd omin is in laur-point knee l in g or supine lying.
Alr ea d y, I was th inki n g of what
posi tions, ra nge o f motion to work i n and the loadin g o f the exercises. It was clear t h a t comfortable starting positions for the exercises probably would be a combi nation of lyi ng and stand in g deloaded . The a im o f the active exercise t herapy was to take away any fear and a n xiety that p hysical ac tivity wou ld increase the symp toms . 1IIET sho u l d act as a posi tive coping strategy, eas ing symptoms as well as the distress and anxiety he was
experiencing. By desi g n in g an exercise programme that is comfortable for him to do, he will be put in a posi tion where he again is in con trol of his own body, that is, controlling the si tu ation of havin g back pain with
For e x amp le , for type III presentations, a MET pro
sci atica .
gra mme could consist of fo u r global exercises a n d
important to minimize any ps ychological issues of the
C on seque n t ly, I fe lt q u i te ear ly that it was
fou r semi-glob a l exercises , where t h e m o s t comfort
pain experience and thereby gain the pa tien t ' s trust
able exerc ise is r e p e a te d twice . G lo b a l a n d semi - gl ob al
from the start. In addition to the positive ps ycholo g ica l
exercises are p er formed al ter n a t i vely.
effects of exercise there are also the ad dition al p hysio
I classified Ol av, based on our conversation, as a type
lo g i c al and neu r ologica l benefits. G raded exercise is a
I presen ta t io n . I thou gh t th at exercises would need to
common sense approac h to regain mo tor control,
be carried out i n itially usin g comfo r t a b le , close t o
muscle bal ance and coordin ation. The exercise wi ll also
pa i n - free star ti n g p os i t io n s performed within his
have positi ve physiological effects on muscle, col l agen
comfortable range of mot i o n . I t could be cou n terpro
a n d bony tissue. It was important that aJl these positive
d u ctive to ask h i m to ignore his p a i n by treati n g h i m
aspects were explained to the patient in detail to op ti
as a ty pe IfI presen t a t i o n a n d mald n g h i m exerc ise
mize his u ndersta nding and retur n to n ormal fu n ction .
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: I
C LIN I CAL R EA SON ING IN ACTION : CASE STUDIES FROM EXP ERT MANUA L T HERAPISTS
In addition to the pain distribution, the 24-hour pain pattern was also typical for a patient with a prolapsed disc experiencing sciatica . One hypothesis is that during the night Olav felt tlne because the disc was not being compressed a n d the nociceptive activation was conse quently decreased. Weight bearing when getting up in the morning and throughout the day then compresses the disc, r esul tin g in increased nociceptive activi ty, lU<ely as a result of the in l1ammatory process, with the end result
b eing an increase in symptoms . Whe n lying
down . Olav effectively decreased the loading on the spine and the disc. resulting in less painl symptoms.
• Cl i n i cal
presentations from
c o mm on variations of the 24-
hour pattern to his classificat ion o f three broad presentations and bjs hy p o t heses regard i n g speci fic sources or pathology implicated . These
are
not sim
ply patterns of academic in terest. rather L hey
a re
each clearly l inked to issues of treat ment select ion and prognosis. In addition . con sistent wit h clin i c al reason ing research. recognition of these patterns and their associated thoughts and act ions occurred .
from the flfst m omen ts' of the in terview.
While pattern r ec ogn ition is a
characteristic of
e xpert i se in all domains. it is also one of th e grea t es t
sources of error in clinical reasoning. It is critical
reaso n i n g co m m e n tary
that clinicians
Ch ap ter 1 d i sc u ssed the need for clinicians to be able
are
not locked i nto their own clin ical
patterns but use pro c esse s of re as sessme nt and
to understand the pe r so n and the pr obl em ' . This
rel1ect i on to reappraise constantly their clinical pat
requ ires skiUs in narrative and physic a l di ag n os ti c
terns in genera l and their prior j u d gm e n t s regarding
'
'
'
p ar t i c ular patient's presenting pattern s . T h i s c on
reasoning: a highly developed organization of bio
a
ps ychosocia l knowledge; professional craft knowl
tinual
edge of ma n u al therapy advice. active and passive
p a tte rn is e viden t
reassessment
of
here
the
pa t i e n t s '
dom i nant
in the clinician's type II
procedures ; and conull u n ication skills to clarify the
prese n tati o n which lies somewhere between types I
p a tie n t's pain experience (effects on life, u nders t a nd
and lIT and only really bec omes clearer th rou gh
ing, beliefs and co p in g ) .
atten t ion and rel1e c tion on the patien t ' s response to
It also req uires
a collabora
.
tive effort with the patient to determ ine and carry
the evolving manageme n t . Similarly. t he clin icia n
of
ha s speciftc patterns of pathology such as d isc and
out app ropriate man agement. All of these
a s pects
clinical reasoning t h eory are evident in this clini cia n ' s pat ie n t enqui ries and
the a nswers to the ques
nerve root that
ar e
recognized . ye t these hypotheses
do not dictate recipe treatments. rather t hey provide a
lions. He cle arly takes a broad biopsychosocial
basis ror explana tion and
approach to his pa t i e n t s and endeavours to under
itseU' is guided more by t he presenting
commu nicat ion : tre a t ment
sta n d both t h e person and the problem, i mportantly
impairments . This. we believe. is
a
disability and
critical d istinction
clin ica l hy po t h es e s on pat hology a r e oflen not
a lso tailorin g his management to Ius assessment of
as
presenting psych osocial and phy sic al issues . Patter n
v al id ated and as such mllst remain as hypot heses. In
re cogn i t ion
acquired th ro ug h a combination of
contra st as discll ssed in Chapter ] . decision making
is
bas ed on disab il i t i e s and impairments ( with ca rerul
a central, but not limiting, feature in his reaso n ing.
considerat ion of pathology ) is argu ably more accu
.
research and retlective experience-based evidence.
our
.
combi nation of prior educat i on ,
rate. more patient centred a nd. from the pe rspec t ive
p e r sonal experience and familiarity with current
of the biopsychosocial m od el or h e al t h and di sabil i t y.
That is. through
a
a pe rs on a l orga nization recognizable patterns in
research, he has c on s tr u c ted
less likely to encourage paLhology-rocu ssecl u n helpful
of knowl edge comprising
t h inking o n the pm't or the patient.
tE
P HYSICAL EXAMINATI ON
Un d ress i n g
Ne u rological assessment
O l a v found i t d i mcul t t o take off h i s shoe s . trousers
Olav had n o problems w i t h regu l ar walld ng o r with
and shirt. It was obviously painful to move and bend
walldng on h i s heels or toes. He was able to do 28 heel
the spine while undress ing
rises on the right l eg and 19 on the left side. ind icating
.
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1 9 A S O FTWA R E P RO G RA M M E R A N D S P O RTS MAN W I T H LOW BAC K PA I N A N D S C I AT I C A
that there was some weakness in the left caLf muscle
(the extension movement starts by ex tending the
(supplied by S l IS 2 ) . He had a positive sciatic nerve
head and neck and then t h e extension movement
stretch test in a standing weight-bearing position .
moves caud a l ly. fi n a l ly extendi n g the lower lumbar
reprod ucing his symptoms down the back of his left leg
segments) c a u sed pain i n the back and the lower
when passively flexing the hip above 45 degrees. In sit
extremi ty. When mov i n g the back the other way, i n
ting. he a lso had a positive s l u mp test on the left side,
a caud al-cran i a l d irection ( the extension movement
vvith provocation of a deep b u rning pain in the pos
starts by rotati ng the pelvis ven trally moving the
terior part of his thigh and d own the back of his cal f to
lower
the anlde. The patellar reflex was similar and normal
ca udal-cra nial d i rection ) , p a i n was fel t i n the back
lumbar
segments
i n to
extension
in
a
b i latera lly. In supine lying, he a lso had a positive
and the lower extre m ity. The symptoms were repro
straight leg raise test on the left side at 45 degrees , with
duced and i nc reased at end-range when the tests were
the same pain pattern as was prod uced with the slump
repeated . P a i n i n t he back o n ly was a l so i n c reased
t�st and the weight-bearing sciatic nerve stretch test.
when side l1exing the l u mb a r spine to either side. b u t
The Ac hill es rel1ex on the left side was slightly decreased
more so t o t h e left th a n t o t h e r i g h t . c a us i n g a l i m i ta
compared with the right. During sensibility testing. the
tion i n the ra n ge of movement both way s . My general
patient reported slightly decreased skin sensation l at
i mpression was that Olav was hes i t a n t to move his
erally on the left leg (S I dermatome ) . All other nerve
spine too far i n a ny direction because of h is fea r of
provocation tests were negative including prone knee
i n c reased pain.
bend ( femoral nerve stretch test) . Except for the area mentioned above, h e had normal skin sensitivity with no paraesthesia or anaesthesia. No other lower limb
Local segmenta l m o bility tests
wealmess was detected and there were no cord or
of the spi n e
cauda equina symptoms or signs.
Testing of passive physiological i n tervertebral move men t for extensionlf1exio n , side flexion and rotation segmental hyper/hypo/normal mob i l i ty of the l u mbar
Posture
spi ne in side lyi n g revealed a distinct resistance to
In the sta n d i n g pos i tion , Olav demonstra ted a slight
movement (Evj enth and Hamberg, 1 9 8 8 : Kaltenborn ,
l a teral deviation /shift of the spine, with a convex scol i
1 9 8 9 : Norske Fysioterapeuters Forb u n d . 1 9 9 8 ) . Olav
osis to the right i n the lumbar spine a n d a compen
resisted the movement because o f p a i n a n d probably
satory scoliosis convex to the left in the mid-thoracic
because of his fea r of increased pain with movement.
spine. When he looked in the m i r ror over the last
As a resul t, Olav had decreased local segmen t a l mob il
2 weeks, Olav had no ted that his trunk was deviating
ity of a ll lumbar segments. This was also the case in
to t he r i g h t . The heigh t of the i l iac cres ts were e q u a l
the thoracolumbar j unction and the middle and lower
b i lateral ly a nd so were t h e a nterior superior and pos
thoracic spine.
terior superior i l iac spines. He also had a straigh tened l u m b ar spine with a loss of the normal lordosis. The hip
Active and passive flex ion a n d extension movements
Glo bal m o bility tests of the
of the h ip j o i n ts bil atera lly were ful l r a n ge but were
spine and pelvis
g iving p a i n a n d disco mfort in the lower l u mb a r spine
Active movement testing o f the spine in the stand
when the movements were taken to the end o r range .
ing (weight-bearing) posi tion revealed that Olav kept
F o r example, whe n Olav w a s lyi n g supine and t h e h i p
his lumbar spine stra ight when bending fo rward . He
j o in ts were passively l'lexed a bove 9 0 degrees. there
was able to touch the middle of his lower leg w i th his
was an accessory posterior rotation of the pelvis with
fingers . b u t fur ther movement was l i m i ted by a n
accompa nyi n g llexion of the lumbar spine, the move
i ncrease i n b ack a nd l e g p a i n . Lumbar extension was
ment o f the spine giving pain in the lower back.
reduced by i ncreased pain i n the back and down the
Rota tio n s . abduction and a d d uction o f the h ips were
leg. Extending the spine in a cran ial-caudal d i rection
ful l range and symptom free.
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C L I N I C AL R EAS O N I N G I N ACT I O N : CAS E STU D I E S F R O M E X P E RT M A N UA L T H E RA P I STS
d o w n the leg . This t e s t was r ep e a te d several t i m e s w i t h
The pelvis an d the i l i osacral j o i nts No dysfunction was fo u nd of the pel v is whe n tests were performed i n stand i n g ( we i g h t- beari ng) or ly i n g
( non-weig ht-beari n g ) positio n s . Forwa rd ben d i n g tes t . i ps i l ater a l ki netic tests i n sta n d i n g. a r t h ro k i nematic tests of
craniocaudal
tra nsl ation .
a n teroposterior
tra n sl a ti o n in lyi n g o f the sacroiliac j oi n ts (Lee. 1 9 9 4)
n o c h a n ge i n s y m p to m s However. t h e symptoms were .
ea s ed when he lay d ow n in the psoas position ( s up ine ly i ng with h i ps a nd knees flexed to 9 0 d eg r e e s w h i l e resti n g t h e lower l e g s on
(l
squa re
b o l s te r ) S i U i ng o r .
l e a n i n g fo rw a r d i n creased t h e s y mp to m s in h i s back and d o w n h is lerr l eg
.
a nd gapping tests of the iliosacral j o i nts b i l a t er a l ly were a l l norma l . A ga i n . tests 0 [' the p e l v i s a n d the the iliosacral j o i n ts resulted in moveme n ts of t h e lower l u mb ar a re a , t h u s provok i n g p a i n i n t h e l u m b a r a rea w i t h some rad i a t i n g pain down the posterior left thi g h .
Pal pati o n of soft tissue Pa l p a tion of s o ft t i s s u e . i n c l u d i n g t h e b a c k muscles. was a l s o pa i n fu l . espec i a l ly i n the l ower l u m b a r s p i n e . O n h i s l e ft side. h is
g l u te u s med i u s a nd m i n i m u s had
d i st i n c t t r igge r poi nts a n d prod u c ed re fe r r ed p a i n i n to
the pos te r i o r a n d posterol a tera l p a r t s of t h e t h i gh
P rovo cat i o n tests The s pu rl i n g tes t ' for the lower back. '
co mb i n i n g
rota
when p a lpa ted and m ass a ged .
t i o n a nd s i d e flex i o n to the left in ext e n sio n w i th some co mpressi o n ( pressi n g cau d a l l y o n his sho u ld e rs ) . repro d u ced a n d i n crea sed h i s symptoms i n the b ack
E l o n gati o n o f soft tissue/ m u s c l e length
a n d the left leg w h e n performed in either sitting or
The p a t ien t had s h o r t e n ed i l iopsoas a n d q u a d riceps
s tan di n g In prone ly i ng
mus c l es
.
.
Olav fo u n d the spri n g i ng
.
although both tests r e p ro d u c ed his back
test over the spin o u s processes u n c o m ['ortable. espe
p a i n ma k i n g i t d i ff'i c u l t to eva lu ate t h e true length o f
cia Uy at the lower t h ree lumbar segments. where pain
t h e musc les .
i n the bu ttock was
.
reprod uced w ith o n ly gentle r hy th
mic pressu res performed in time w i th the patie n t ' s bre ath i n g
p a t ter n .
Compression
of
the
i n cl udi n g nutation a n d co u n t e r- n u ta ti o n
.
s a cr u m
.
was also
p a i n fu l . When perfo r m i n g t h e provoc ation tests of the s p i ne a n d sacru m , there was a ge n era l i m pression of hy pomobility of t h e l u m b a r segments. with firm resista nce fel t when perfo r m i n g the r h yth m i c mobil ity tests ( i . e . postero a n terior
in terver tebral move
me n ts ) . However. it was not poss i b l e to deter m i ne the
Rad i o l ogical fi n d i ngs Racli o g r a p h s re ve a le d norm a l bony s t r u c t u re of the l um b ar spi ne and n o r m a l h e i g h t between each of the t h r ee l ower ve r te b rae. However. t h ere was
a
'
no r m a l
( CT) s c a n n i n g reve a l ed a mid- to left-s i d ed pro l apse o f the L 4 I VD ( F i g . 1 9 . 2 ) .
ca us e of the hypomo b i l i ty beca u se or O l av ' s i nabi l i t y to rel ax fu l ly when experienci n g pai n .
M a n u al tracti o n Oe\oadi n g o f the l u m b a r spine throu g h m a n u al t r ac
t i o n in sitting and in supine ly i n g eased the symptoms i n the leg and the lower ba ck
.
M e c h an i cal positi o n i ng of the s p i n e W h e n side g l iding ( i n both d i rections. exten sio n / side flex ion ) was a p p l ie d i n s t a nd i n g and i n prone lying i n a n attempt to
ce n tr a l
iz e the sy mptom s the patie n t .
i n s tead e xp e rie n ced incre ased p a i n a n d d iscomfo r t
'
spina b i fi d a a no m a ly of L 5 . C o mp u ted to mography
F i g . 1 9 .2
C o m p u ted to mography i l l u s trati ng m i d - to
l e ft-s i d e d pro l a pse of the LS i n t erverte b r a l d i s c .
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1 9 A S O FTWA R E PRO G RA M M E R A N D S P O RT S M A N W I T H LOW BAC K PA I N A N D S C I AT I C A
R E AS O N I N G D I S C U S S I O N A N D C L I N I C A L R E A S O N I N G C O M M E N TA RY
D
Please discuss your reasoning fol l owing the
prolapse provok ing an i n ll a m m a tory reaction o r the
physical examination using the hypothe s i s
S l nerve root.
categories : pain mechanis m s , prin cipa l physical i m pair m e nts identified, source of the sym pto m s ,
So u rce of the sym pto m s
precautions t o m a n agem ent, and the m a n age m e nt con sidered appropriate .
W h i l e I feel cons i d era tion o f the s o u rce o f the symp toms i s importa n t . I a lso bel ieve t h a t some c l i n icia ns
• Clinician's answer
overly ["oc us on orga n ic ti ss ue st ructu res a n d pa th
Pain mechanis m s
ology i n the s t r uctures . Resea rch has shown t h a t
Pa i n mec h a n i sms c a n b e d i v i ded i n to li ve c a tegories:
is ve ry l i ttle corre l a t i o n between i mp a i rmen ts
a nd
d isa b i l i ty
a
there
p a tie n t s pain leve l . '
( Wad d e l l et a l . . 1 9 8 2 :
Wa d d e l l . 1 9 8 7 ) . Therefore. i n prac t ica l work with
• sen sory • neu roge n ic ( s c i a t i c a )
i n d i v i d u a l patients. t h i s means t h a t some patien ts w i l l
• cen tra l p a i n mec h a n i s m s ( ne u ra l p l as tic i ty )
h ave been o n long - term s i c k l eave w i t h m ini ma l symp
• a lTec t i ve ( psyc hosoc i al e l e m e n t s . such as psyc ho
tomslimpalrme n ts . w h i le ot her patie n ts wil l fu n c t i on q u ite wel l ( e ve n work ing ) \-\lith sig n i fica nt pain a nd
log i c a l stressors and social in t eract ion )
pathology. To con fuse the m atter even more. researc h
• a u ton o m i c a n d motor. The most relevant pain mec h a n ism s for Olav were sens ory a nd neu rogen ic (Olmarker and Ryde v ik . 1 9 9 2 ) . My worki ng hy pothesis was that nociceptive activation w i t h a possi ble in n anun a tory reaction a t t he outer/ l a teral IVD a n d an i n ll amed nerve root caused the s igns
and symptoms . F i n d i ngs [rom th e patient history ( e.g. area. be h av iou r a n d h istory of symptoms) and the
correc tion. provocation tests . segmen tal mobi lity assessment
p hysicaJ e x a m in a tion ( e .g. posture an d pos tu re
and neuro log ica l tests ) supported t h ese p a i n mech a n isms. T h ey were fu rther s upported by the CT sc an s howing a prol a pse d L S disc.
h a s also d oc u mented t h at increased stre ngth and e nd ur a nce of the back mu scles
a fte r
3 mo n t hs reh a b i l i
tatio n progra mme with exe rcise therapy ( Man nion e t al . J 9 9 9 ) could n o t be exp la ine d by m o rp h o l og i c a l .
c h ange s
i n the back m u s c les ( c h a n ges i n fi bre p ro por
tio n a nd fi bre s i ze : Kaser et a l . . 2 0 0 1 ) . Rath er, sign i Il
active rehabil ita tion appeared to be mainly a co nseq uen ce of c ha n ges in n eu ral a ct ivation ( n eu romusc u l a r
ca n t cha nges i n mu scl e pe rformance after su c h
a d ap ta tions) of th e l u m b a r muscles a n d psychologi cal c h a nges s u c h a s i n c reased motivation to tolerate pain ( Ma n nion et a l . . 2 0 0 1 ) . T h e prac tica l i mp l ic a t i o n is that there is l ittle or no cor relation be tween c ha n ges in orga n i c tissue structu res. symp to ms a n d fu nction.
Principal p hysical im pairments
Regarclin g a structuraJ cha nge l ike a prol apsed IVD.
One of the main i m pa i r men ts wa s O l av ' s extre mely
some palients will become symptom free through trea t
stiff spin e . or rather the d ec re ased range of moti o n in
ment or na tural reso l u ti o n even if there is con llrmed
ev iden t when s pe C i fic al ly
pathology such a s IVD p r ola pse. because prolapse a n d
aU directio n s . This wa s
a lso
testing Ilexion. extension . side Ilexion and ro tation
bu lgi ng discs are also a normal p henomenon a mong
mobili ty of the L S . L4 . L3 and L2 segmen ts ( Evj enth and
asymptomatic individuals (Jensen et
Hamberg. 1 9 8 8 : Kal tenbor n .
1 9 8 9 ) . The d ecreased
ing the assessment and i n terpretatioQ o f clinica l fi n d
mob il i ty was pro b ab ly a secondary reacti o n to the
ings more impor ta n t than imaging studies (Khan et a l . .
a l . . 1 9 9 4 ) . mak
pain provocation and w i l l norma l ize when the pain
1 9 9 8 ) . Yet other patien ts will have structu ral changes
his pos t ural impairme n t had
and c l i nic a l find ings that do correlate with their func
decreases . S i m i l a rly.
likely d eveloped at le as t i n p a r t . as a means to avoid
t io n a l statu s . I fel t th at O lav's s ymptoms did correlate
pa i n . The decreased range o f motion and neural fu nc
with a struc tural c ha nge W<e a d i sc pro la pse , a n
tion were pro ba b ly a l so a res u lt of th e pain and
impression s upported by h is C T scan fi nd ings (Ku s lich
noc ice pt ive activa t i o n . pos s i bl y t hrough an L S IVD
et a l . . 1 9 9 1 ) . However even if there were no positive
.
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.
C LI N I CAL R EASO N I NG IN ACTIO N : CASE STU DIES FROM EXPERT M A N UAL THERA PISTS
fi n d i ngs on the CT scan, I s ti l l wo u ld treat hi m with a simi l ar approach , because i t is possible to have sciatica even when there is n o verified prolapse. Olmarker and Ryd evik ( 1 9 9 2 ) have hy pothesized that it is possible to have cracks in the IVD and that materi a l from the n ucleus pu lposus can slip through these 'cracks' elic it i n g an a utoi mmune reaction when nucl ear ma terial mal<es contact with the o u tside tissue. The end result is
an inl1amma tory process affecting the nerve root a nd resulting i n sciatic p a i n . Such a hypothesis has been conftrmed in animal studies (Olmarker and Ry d e v ik , wh ich
1992),
demo nstrated
th at tissue from the
n ucleus pulposus provoked a strong inflammatory reac tion when pl aced in con tact with the scia tic nerve in pigs. However. bec a use it is so
difficu lt to mal<e a ' tissue
at fa ult' diagnosis i n human s , and the fact that struc tural c h a n ges of tissue do not necessarily correlate with symptoms and function, it is the patient's reaction/pain behaviour wh ich i s the most important fmding to screen regard i n g choice of tTeatment strategy (Khan et al .
.
1 9 9 8 : Main and Booker, 2 00 0 ) . Tradi tional tests from orthopaedic medicine/manual therapy are still impor tant but secondary to the patient's pain behaviour.
Regard i ng th e issue of s truc ture versus function, i f there i s a n objective fi n d i ng o n C T scan at the right leve l
and s i d e it is easy t o foc u s on t h e structural change and ,
believe that the only thing that might help i s surgery ( e . g . taldng the prol apse o u t ) . What I try to explain to my patients, and this was also the case wi th Olav, is that as
much as S O D!., of the population wi thout any pain
h a ve bulging d iscs and prolapses (Jensen e t ai. , 1 9 9 4 ) . F u r ther, when the patient becomes symp tom free thro ugh treatment and the body's own self-h e a l i n g mec h a n isms, t h e prolapse i s prob ably stUI there and i t m ay take a good t i m e before it par tly d ries u p. For Olav, the findings from clin ical tests (physical examin ation) su ppor ted his repor ted history. DUTerent
clin ical tests reproduced his symptoms and the sy mp toms appeared in well-recognizable ana tomical areas and dermatomes in the b ack and lower extremity.
All
this suppor ted the view that Olav had a type I presenta
tion with straighlforward sciatica possibly caused by a prolapsed LS IVD. The clinical fmd ings supported the original working hypotheses ge n er a ted from the medical history. The posi tive fmdings from the nerve s tretc h tests. such as the slump test a nd the straigh t leg raise test, indi cated th a t there was an inl1ammatory process involving the Sl nerve root. This was also suppo rted by the diag nosed prolapse of the LS IVD eviden t on the CT scan .
P recau t i o n s to manage m e n t There were no serious precautions to trea tment. Active gr aded exercise therapy such as the MET approach is probably one of the s a fest treatment approaches avail able for treating patien ts with sciatic a . However. care should be taken so that the exercises do not signilkantly increase the patient's pain. Close commu nication with the patient regarding the symptoms experienced during the exercises, and whether they increase. is i mportant for the management to be s Llccessfu l .
Ap pro p ri ate m anage m e n t The key fmdings range from impa irmen ts lil<e pain a n d decreased range of motion of the s p i n e t o disabili ties in d ifferent dai ly activities . !vffiT is a ppropriate lor man aging all these impairments and disabili ties . I t is the aim of MET to trea t both signs and symptoms ( impairments) , in a d d i tion to improving function on both an ind ividual level (disability) and a societa l level ( h a n d icap) .
• Cl i n ical
reaso n i n g com m entary
Here t he c l i n ician expl ic itly sh ares h i s p h i l osophy i n that. while he hyp o the siz es about pathology and clearly screens lor se r i ou s pathology (e.g. s pin a l cord. neurological and
c aud a
equina test s ) , h is man age
ment is based on t he pat i en t ' s presenti n g d isabilities
( i .e. activity and p ar t icip a t io n res t rictions) and impa irments. R a th er than se l ec tively u s i n g evidence from the l i te r a tu re as occurs when someone wants ,
to a rg ue their favourite hypothesis
(see errors of rea
soning discussed in Ch. 2 6 ) . here t he clinician cites evidence
substantiati n g processes
pathology can be symptomatic on its
whe r e by own
IVD
and irrita
tive of adj acent neural t issue wh i l e also repo r ti n g the l i terature that documents not all pathol o gy is symp tom a tic. This is precisely t he sort of c riti c al and open minded
reasoning
expec t from an expert clear views. he is a l so u nm is
we
clinician . Wh i le he h as
takably rel1 ective and open to c ha n g i ng those views, per son a lity and
reasoning att ributes that lead to
continued learning regardless of years of ex pe ri enc e or status. Ch apter 1 claims that
manua l therapists'
thinking and j udgments extend over a range of int er
related areas, which were ca lled hy pothesis cate gories .
Th i s
is
ev i dent
here
in
the
c l inician's
reasoning regard ing pain mechanisms, p hysical impairments. so urces of the symptoms, precautions to management and m a n agement itsel f.
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1 9 A S O FTWA R E PRO G RA M M E R A N D S PO RT S M A N W I T H LOW BAC K PA I N A N D S C I AT I C A
""��-�Explanation of intended .: management
get better. You have experienced that sitting at work mal,es you worse, and that the best pOSition
,.
to ease the pain is lying down . But I u nderstand
Trealment commenced as I went through the assess ment in that my assessment is a part of the treatment and the actu a l trealment is a part of
a
continuous
assessment. However. after fm ishing the assessment I sat down with O l av and attempted to expl ain my fmd ings, how they cou ld be interpreted, and what treatment I would suggest for managing his pain a nd disabilily.
First of a l l . I spent some time explaining what pain is: nota bly that pain i s a mul tid imensional experience, pri marily with a sensory and d iscri m i n a tive d i men sion but a lso with a cogni tive and eva l u a tive d imen sion and a motivatio n a l and affective d i mension, I a lso expl a i ned that w i t h time the sensory d imen
sions becomes less i m porta nt and the cognitive and emotional d i mensions of pain become more invol ved
(Main et a l . . 2 0 0 0 a , b : Main a n d Brooker, 2 0 0 0 ) , T he exp l a n ation I prov i d e d was essen t i a l ly as fo l l ow s :
th at you cannot lie down forever, and you h ave also tried th is: when you then get up a n d start to move, the pain is b ack to t he same level as before. This is a fruslTati n g s i tuation. Wh at we have to try is to get you active, but at a level that is acceptable for you . Proper pac i n g is the key issue, both when you come for treatmen t and when you are at home or at work. I
am
going to put you
immed i ately i n to an exercise programme, using starting postural positions that you fi nd comfo r t able, suc h as lying and stancling, which are k nown as deloaded or non-weight-bearing posi tions, With a d eloaded exercise, I mean that through the exercise some of the weight is taken off your spi ne. One way of d e l oacling the back at home is to g rasp the top of a door with both ha nds and then hang by your arms, which wi l l tal<e some o f the weight off your back. I t is i mpor
You r b a c k and l e g pain are probably caused b y an
tant that the treatment is comfortable and d oes
i n l1ammatory reaction in you r b ack irritati ng the
not sign ificantly i ncrease the symptoms. We have
sciatic nerve, S tructures i n the far low back, such
to concentrate on what increases the symptoms
as the intervertebra l disc at either the L4 or L5
and what eases the symptoms , a nd i t is important
level , are to b lame, However I am not q u i te sure i f
to find the exercises that ease the symptoms,
you h ave a prolapsed interver tebra l disc, I f you do
choosing starting positions that give you a s little
not have one, it is sti l l possible to have the same
back pain as possi b le, This is done by tri a l and
symptoms as i f you did have a prolapse, It is not
error and it is important that we find an accept
dangerous to have sciatica, and i t is not danger
able leve l of load ing for your back . otherwise you
ous to have
possible prolapsed disc, What we
will not get the expected improvement and may
have to deal with and treat are the impairments
end up with long-lasting back pain and disability.
such as pain , sti ffness and decreased range of motion . Researc h has shown that as much as
However, your prognosis is good and within 2 to
50'){) of the general population have a bulging or
suggestions are threefold: first, what to do a t
prol apsed disc and no symptoms , so such struc
home, secondly, w h a t t o d o at work, a n d finally,
tural
c
a
h a nges are normal . However, we do not
3 months you should be signil1ca ntly better. My
what to do at the clinic,
rea lJy know why some peop le get back pain and
Treatment at the clinic, Lets look at the last
sciatica while others do not. It may be hereditary,
point first and what to do here. I would like to put you in to a graded exercise programm e, which
where some people have a narrower spinal canal and are more prone to int1ammatory processes.
we call meclical exercise therapy or MET, ideally
In your case, the l i fting work you did in your cel
using seven to nine exercises, and doing three
lar may h ave overloaded tissues in your lower
sets of 30 repetitions with in the range of motion
lumbar spine and discs, causing an inllamma
that is comfortable and close to pain free. The
tory reaction , The pain you now experience will
a ims of the exercises are to decrease the pain you
also i n iJ uence you psychologically. Because the
experience, help you to become more t1exible and
methods you tried earlier to get rid of the pain are
generally to improve your functio n , thus increas
not working n ow, it is quite normal to get frus
ing you r tolerance for physical loading and psy
trated and scared . The pain is still there and you
chological stress. I want you to attend three times
are worried about your work and what to do to
a week and the exercises will tal(e approximately
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. .
1
C LI N I CAL REA SON I NG I N ACTIO N : CA S E STUDIES FRO M EX PERT MAN UA L THERA PISTS
h o u r each time. La te r
.
i s to r ed u c e the i n l1ammatory p roc e s s
when you start to
.
hence
improve. the prog ramme Vlri ll take l){ h o u r s
you should not do things that w i l l m a i n t a i n or
incl u d i n g a warm up. The e xe r c i se prog ramme
i n crease the p a i n you fee l At t h i s stage. I do not
w i ll consist of exercises t h a t are comfortable to
want yo u to d o a ny h o me exercises. bec a u se i f
.
p e rform t h u s avoid i n g s t i m u l a ti o n of the pain
you shou ld get wo rs e w e wi l l no t k n ow w h a t
receptors or s o c a l l ed nociceptive receptors. b u t
m a de y o u worse. T h a t i s . w h e the r i t w a s t h e
rather sti m u l ating mec h a noreceptors from m u s
exerc ises here. t h e home exercises o r some t h i n g
.
-
c l e s . te n do n s
and j o i nts res u l ting i n a b lock i n g '
else. When yo u have con trol over the s y m p to ms
'
r wi l l g ive you ple n ty of exercises to do at home.
of the pai n . The exerci s e s wiJl a l so increase the
c irc u l ation to m u scles. tend o ns. j O i nts and the
What to d o a t wo rk . Try to sit a s l i ttle as pos
bony s tr u c tur es o f the spi ne. T h ere i s a l so some
s i b l e . We know that s i t t i n g will increase yo u r
evidence that the i n te r vertebra l disc itself rea cts
symptoms. so t r y t o a l te r n ate b et ween s ta n d i n g
lying. Stay at work for o n l y a few hours.
pos i t i vely to an ap pr op ri a t e p hysical load ing. We
and
w i l l test o u t three d i ffere n t exe rci s es t oday
W h e n tr a v e l l i n g to and fro m work ta lce
.
What to
a
t a x i so
that you c a n l ie d ow n in the b a c k seat. t h u s n o t
do at home. Try to stay active. b u t lie
d ow n when symptoms a re i n c reasing. Even
h av i ng t o s i t in t h e unco mfor table l1 exed s it t i n g
though you m ay feel better o n some d ays. r do
position that i n creases y ou r pa i n . If exte n d i n g
not
think l i ft i n g or heavy p hy sica l work is a good
yo u r spine feels
th i n g a t the mome n t . The im portant t h i n g now
c o m fo rt abl e
t r y t o stay i n t h a t
posi t i o n .
REASONING DISCUSSION AND CLINICAL REASONING COMMEN TARY
D
ca n n o t .
Man ual therapi sts have a gol de n
Changing pati ents' un dersta n ding and fee l i ngs that
on what he
you j udge to be 'im paired' , unhealthy or represent
opportu n i ty to work on t hese matters because we
potential obstacles to their recovery is o bviously
spend so much time together with the patient. So as s p ecial i s t in
manual t hera py. I u t i l iz e cognitive
important to you. However, this can a l s o be very
a
difficult to achieve, especia l ly for pati ents whose
behavioural therapy in the exerc i s e room. s pe n d i n g at
perceptions and bel iefs are well established. Can
least 1 hour
with t he patient two to t hree t imes a week.
When NIET is used as an
you com ment on the strategies you use to assist
o p e r a n t cog n i tive
be hav i o u ra l appro a c h . the focus is on treat i n g pain
patients in changing the i r percepti ons?
be h a v io u r a nd dis a b i l i t y rather t h a n fOCUSSing prima
• Cl i n ician's answer
rily o n i m pa ir m e n ts (Keefe et a l . . 1 9 9 2 , 1 9 9 6 ) . This is a
I a g ree that c ha n g in g patient's pe rcep t io n s and beliefs
we have been t a u g h t to l o o k for i m pa i r m en ts and d eal
great c h a l lenge. espec i a l ly in manual the ra py where .
may be diffi c u l t . S om e of the basic criteria that must be
with s pe c i fic moveme n t disorders to normalize fu nc
fult111ed to be able to c h a nge negative perceptions and
tion
be l i e fs are to h ave close and effective commun ication
The qu estion i s when to tre at local imp a i rm e n ts and
(Gifford and Bu tl e r 1 9 9 7 ; Zussman . 1 9 9 7 . 1 9 9 8 ) . .
with the patient. being ab le to listen to the p atient, and
when to go glo b a l a nd ' treat' b eh avi our For p atie n ts
pr ovi d in g exp l an a t i o n using p l a in simple l anguage.
with chronic l o n g l a sti n g p a i n . a q uo ta-ba sed exer
.
-
When you are Vlrith a patient over a period of time. i t is
cise progra m m e with a ti me-c o n t i n gent appro a ch
importa n t to try various ways of explaining. with the
may be a ppl i e d . focus s in g on im p r o ve me n t i n fu nc
t heor y you want to get across linked wi th clear prac
tion i n stead o f on symptoms o n ly. However. for other
tical examples. By r ep ea tin g this expl an ati o n and the
patients. who h ave n o r m al pain behaviour wi th p a in
wel l- k nown a n d relevant a n a tomic area where
changes you wan t to see, yo u inc r e a se the li keli hood of
in
the patient graspin g the message. S hared decision
sym p t o ms can be reprod uced and where i t i s p o s s i b le
a
.
making and empowerme n t is a must. with the patient
to d i a gn o s e an orga n ic t i ssue s tr u c t u re at fau l t .
s lo w ly becoming more a nd more in charge o f t h e
t h e approach i s fairly straigh tforwa rd. apply i n g a
treatment and fo c u s s ing on wh a t he c a n do i n stea d o f
p a i n -conti ngent approach with comfortable cl ose
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1 9 A S O FTWA R E P RO G RAM M E R A N D S P O RT S M A N W I T H LOW BAC K PAI N A N D S C I AT I C A
to pa i n - free exercises wor k i n g thro u g h com fo r t a b l e ra nges o f m o t i o n norm a l izin g
both function a s well
b a c k because I have a prolapse' . T here are many more such b e l iefs .
as the stru cture a t fa u l t ( Torste o sen . 1 9 9 0 . 1 9 9 3 :
Ch a n gi n g p a ti e n t s ' negative beliefs a b o u t the i r
To rstensen e t a l . . 1 9 9 4 ) . I feel i t i s i mp o r t a n t t o b e
b a ck p a i n is often critical to successfu l m a n ageme n t .
a b l e to u s e b o t h time- a nd p a i n-co n t i ngent t re a tment
Hel p i n g t h e m t o understand t h a t t h e p a i n is n o t
in rela
d a ngerous and th a t i t is n o t d angero u s to move the
appro a c hes an d to choose the right approach
tion to the pa tient's pai n b e h av i o u r and prese n tation
back cmd to become more p hys i c a l ly a c tive so t h a t
of s i g n s a n d sy m ptoms . In Olav ' s case a p a i n-c o n t i n
they c a n retu r n t o w o r k , e v e n t h o u gh t h ey bel ieve t h a t work is d a n gero u s for their back. is o ften very d i f
ge n t approach was used . The a i m of t h e treatment is to d e a l w ith a ny nega
fic u l t and p rob a b ly the b iggest c h a l l e n ge we h ave as
tive percep tions a n d bel i e fs a b o u t back p a i n . c h a n
m a n u a l t h e ra pis ts I t is a l so important to m ake the
g in g th em to somethi ng positive. Bec a use patients vary
patient aware th a t to a c h i e ve t h i s w i l l ta ke s o m e time.
in t h e d e g ree to w h ic h t h e y a re re a d y to e n gage i n n e w a dap tive be h aviours . I h ave fo u n d t h e fol low in g mod e l ( Proc haska a n d DiCleme n te . 1 9 8 2 : P roch a s k a
a t l e a s t 2 to 3 months to beg i n w i t h . and t h a t the fi rst
et a l
..
1 9 9 4 ) usefu l as
a
broad g u ide for m y i n ter
raise doubt. increase patient's
percep tion o f the risks and pro b l e m s
associated
with their current behaviour. t i p t h e b a l a n ce. evoke re asons
2 . Contemplation:
to c h a n ge. e mp h a s i z e the risk of n o t c h a n g i n g . s tre n g t hen t h e p a t ie n t ' s se l f-e ffi c acy for c h a n ge
of
curre n t behav i o u r. 3 . Preparation :
My
m os t
a
m a n u a l t h e ra p i s t i s .
p a ti e n t w h i le t h e p a t i e n t is exerc i s i n g .
Through my
behaviour wor k i n g with the p a t i e n t i n the exercise room, I a m h o p i n g to ach i eve s o me kind o f b o n d in g between myse l f a n d t h e p a tie n t , m a k i n g t h e p a ti e n t u n d erstand and bel ieve i n w h a t I a m s ay i n g and d o i n g . U v n ils-Mo berg ( 1 9 9 8 , p p . 8 1 9- 8 2 0 ) s ay s :
a ssoci ated with an u n i fied patte r n o f p hysio l o g i c a l a n d behavi oral events . l e a d to phys io .
help t he p a t i e n t to take steps toward
c h a n ge. review the progress : renew motiv
.
l ogi c a l a d a ptations necessary for re l a x a t i o n , d i gesti o n ,
5. Maintenance:
i mp o r t a n t j o b as
. . . posi tive soc i a l i nteractions a n d e m o t i o n s are
he l p the patient to d e term i n e t h e
best cou rse to take i n seek i n g change. 4 . Action:
period wi l l i n m a ny wa y s be p a i n fu l for the p a t i e n t a n d a s t ruggle for b o t h t he patient a n d t h e t h e ra p i s t . therefore, to m o t i v a te the p a t i e n t . s u p p or t i n g t he
action and commu n i c a t i o n w i t h my p a t i e n ts. 1. Pre-contemplatiol l:
.
a n ab o lic metab o l i s m ,
g rowth a n d
h e a l i n g . T h e correspond i n g men t a l states asso ciated w it h posi tive social i n teractions i n c l u d e
ation a nd commitment as neede d . hel p t h e pa tie n t to review t h e processes
c a l m ness a n d ope n n ess to soc i a l e n gageme n t .
of contempla t i o n . determ i n a tion and acti o n . w i th
In t h e context o f posi tive social i n terac tions a n d
o u t beco m i n g stuck a n d demora l ized be c a u se of
emotio n s , o n e neu ropeptide system conta i n i n g
6 . R e lapse :
oxyto c i n h a s e merged as a c o m m o n r e g u l a t ory
rela pse. To h ave successfu l c o mm u n i ca t i o n w i t h p a tients. the
therapist must express empathy a n d avo id arg u m e n t C ro l l ' w i t h resistance) . It is importa n t to provide i n for mation whi le giving the patient options and c ho i ces .
elemen t . Oxytocin coord i n a tes bot h c a uses a n d e ffects o f pos i t ive soc i a l i n teracti o n s . T o be a b l e to achieve a p o s i tive soci a l in tera c t i o n w i t h p a tients b e i n g trea ted w i t h exercise t herapy i n the
Over the years I h ave become more aware of p a tients '
exerc ise roo m . i t is esse n t i a l for the therapist to be p res
di lTerent belief systems and h o w t h e ir bel iefs c a n in llu
ent with the patient, a n i mporta n t and ru n d a menta l
ence t h e treatment outcome negatively. Patients' beliefs
elem e n t fro m the crite r i a for t h e MET approach . These
have emerged [rom laUein g with family [riends. health
criteria a r e d iscussed i n deta i l i n t h e secti o n below
.
workers of differen t categories and reading popular arti
describing the MET regime n . A fu ndamental e l e m e n t
c les in the media or watching health progrcunmes o n
o f MET i s t h e presence of t h e t h e r a p i s t i n the exer
television. Common examples of statements t h a t often
cise room consta n tly mon i to r i n g the pa tients w h i l e
rellect u nhelpful beliefs or person al perspectives that
exerc i s i n g . F o r m a ny ye ars I
m ay be coun terproductive to the patient's recovery
room every second hour d uring my worlcing day h av i n g
include ' My pain is in the L5 facet j oin t on t he right sid e ' ,
a MET g ro u p consisting o r
because it i s pressin g o n m y nerve ' , 'Rotation is d ange r o u s for my
ferent movement disorders ranging from orthopaedic to
'Th at prola p sed disc must be taken o u t
have been i n t h e exerc ise
up t o five p a tients w i t h d if
vasc u l ar to neuro logi c a l pro blems. In t he ho u r between
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C L I N I C A L REASO N I N G I N ACT I O N : C A S E STU D I ES F R O M EX P E RT M A N UAL T H E R A P I STS
each g roup. [ ei ther assess a new patient or h ave two
shower. and the use of l ow-grade globa l exercises
separa te i ndivid u a l tre a tmen ts each of 30 m i n utes .
l ike j u s t walking for 3 0 to 45 m i n u te s .
A fter the assessment of
a
n e w patien t . I often bring
that patient stra i g h t i nto the exe rcise room to start des i g n i n g / testing out a n exerc ise prog r a nune . The orga n ization of my workin g d ay makes it easier to com bine active exercise t h era py with any other method i n p hysiotherapy. As me n ti o ned above. my role i n the exercise room is
For
a
p a t i e n t with
a
t y p e r prese ntation , a p ain
c o n t i n gent trealment approach is used. wh ere the exercises are graded accord i n g to the patient's p ai n experience work i n g close to pa i n - free. w i t h i n the comfo r table ra nge o f motio n .
to mo tivate the patient and provide positive feedback.
• C l i n i cal
giving the p atien t a new a n d posi tive experience
Expertise i n man u a l t herapy requi res much more
re gard i n g his/ her own body. while at the s a me time a d d ressi n g any fear-avo idance beliefs regard i n g phys ica l ac tivity and work that may exist. If the patient experiences i ncreased pain from the exerc ise therapy. there is a l ways the risk that they m ay drop o u t of treat me n t . This risk is min i m ized when patients a re helped to u nderstand the purpose and p l a n ned progress ion of the exerc ises and that a deg ree of d iscom fort in the ear ly stage is commo n . Being present with the patien t s t i m u lates complia nce and empowerm ent and not dependence. Be ing presen t makes it possi b le to g rade the exercises optimally for the patient to ge t physio l ogical effects Crom the tra i n i n g . res u l ting i n i m proved fit ness a nd improved tolera nce for l o a d i n g . However. malting t h e patient motivated is fund amen tal for being successful. and to motivate a patient "\Tith a type IT and III presentatio n I use the following checkl ist
while worki ng with the patient in the exercise room: • p a tie n t sets baseline of the exercise programme
reason i n g c o m m e ntary
than advanced biomedical knowledge and manual skill s . S uccessfu Uy un dersta nding and managi ng the diverse range of patient presentations that regu l arly
confront
manual
therapists
a lso
requ ires
advanced psychosoci a l knowledge and commu n ica t ion sk i l l s . Chapter 1 presents
a
model o f clin ical
reasoning i n manual therapy. l i n ked to
a
model of
health and d i sabil ity. which h ighl i ghts the impor tance of having
a
nu mber of d i fferen t but related
clinical reason ing s t r a t e g ie s to be able to u nderstand and ' !l1cl Oage' both the person and the problem . While d iagnostic rea soning is expl icit in most thera pists' rea soning for pat ient ' s activi ly/participation restrictions, physical and psyc hosocial impairments. pathobiological
mechanisms, so urces of sympt oms
and contrib u t ing factors . other reaso n i n g st rate gies such as narrative reaso n i n g . i n tera ctive rea s o n i n g . collaborat ive reasoning and teaching are often less-deve loped or tacit ski lls. The explanation prov ided to t h i s patient and the c l i n ician's a n swers
( m anageable. almost easy level) • fo r a type I I a n d type III presentation . progres s i o n
to this reason i n g question are excellent examples of these strategies in practice.
is q u o t a ba sed r a t h e r t h a n p a i n based • prov i d i n g inunediate positive reinforcement
Narrative reasoning refers to therapists' e nquiries
• i gnore pain b e h av i o u r ( roll w i th resi s t a n c e )
di rected toward u nd erst a n d i n g the patien t ' s per
• p a t i e n t i n c h arge o f c h a r t i n g programmes
so n a l story/na rrati ve or the con text of the prob
with a ny nega
lem beyond t h e mere c h ro n o l ogical seq uence of
tive beliefs and negative percep tions about exerc i s e
events. It requ ires try i n g to u n derstand the patient
• good commu n ication style. dea l i ng
pe r s o n
incl uding their perspec tive of the
and d e a l i n g w i t h movement in a posi tive and. i f
as
poss i b l e . hum orous way.
problem (e.g. understa nding. bel iefs . desires. moti
a
.
vation s . emotion s ) . the b a s i s of their perspectives
If the patient experiences i n creased p a i n : • acknowledge t h e fac t t h a t t h e p a t i e n t i s worse • reassure. prov i d i ng clear guidance that i t is normal
to get i ncreased p a i n and t h a t i t wi ll level off a fter a few days • o ffer a n u mber o f su ggestions to ease the i ncrease
i n symptoms fro m which the patie n t can choose:
for example. heat a n d cold contrast b a t hs . hot packs/ice packs to be used a t home. warm/cold
and
bow
the
problem
is
a ffecti ng
their
l i fe .
I n teract ive reaso n i n g relates to t h e t h i n k i n g a n d actions that underpin the rapport and c on fide n ce therap i sts est a b l i s h with their patients (Jones e t a l .
.
2 0 0 2 ) . While socia l izing with patien t s is not typi cally considered
or
a
purposeful act of cog n i t ion
i n g often therapisls must be strategiC a n d pu rp osefu l i n these i n teractions. which then r e a s on
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1 9 A SO FTWA R E P RO G RA M M E R A N D S P O RT S M A N W I T H LOW BAC K PA I N A N D S C I AT I C A
a strategy of reasoning. perhaps account for more o f the s u c cess fu l outcome than has been gener a l ly ap p re c i at ed Collaborative reason i n g relates to the c o n sensual approach b e twe e n thera p i s t and patient to wa rd s the i n te r pre t a t io n of exami nation tlndings. t h e setting of goa l s and priorities . and t he implementation and p rog r ess i o n of treat ment. Re a so nin g should also guide our te ac h i n g of pa tients in that th e r e is n o single approach to teach ing that will be effec t i ve for all patients. S k i lle d thera pists have learned how to mod ify their teaching for individual p a ti e n ts and reassess the effectiveness of thei r efforts with th e s am e critique they g i v e their physical i nt e r ve n tio ns [mportantly, th ese v arious constit ute ing
.
.
sanctio ned in M arch 1 9 6 7 by the Norwegian
Health
Au thorities as a special therapeutic system, code C3 2 ,
O d d d v a r H o l te n , w h o d eveloped MET d u ri n g the ea rly 1 9 6 0 s , was also one of the fo unders o f
m anual t h e r (Torstensen et a I . , 1 9 9 9 ) . MET is ' a n exercise ap proach where t h e patient p er for m s exer cises in speci a l ly de s i gn e d apparatus, w itho ut manua l assistance, b u t bei n g consta ntly monitored by the p hysiot herapist' (Holte n . 1 9 6 8 ) . The pr o g r amm e has
apy in No r way
a n u m ber o f specific criteria:
for Norwegian p hYS i othera p i s t s T he criteria are .
[unda
mental to the organization of the workplace and work
d ay to allow exercise th e r a py to be used efi1ciently to help p a t i e n ts to c h a n ge towards a more heal thy belief sys te m promoting recovery. Conseque n tly one of the most fundamental elements o f the MET criteria is the t hera p i s t being p r e sen t in t h e exercise room constan t ly .
monitori ng the patients while exercisin g . ME T and
manual therapy have been c losely linked
th e apparatu s must be designed [or o p t i mal stimu lation of the re leva n t fu n c tion a l qu a l i ty in qu esti o n : neuromuscular, arthrogenous , circ u lator y
for many years (Holten , 1 9 6 8 , 1 9 7 6 : Ho l te n and Faugli .
and respira tory
riage ' but may also be one of the reasons why many over
• th e effect is ob t a i ne d by the p atien t carry i n g o u t the exercises fro m a d efi ned s t a r t i n g position , i n a s p ec i tlc range of moti o n , against a
graded load
• there is a mi n imu m of 1 h o u r effective treatme n t ( excluding
dressi ng
and
u n d re s si ng ,
s h ower/
bath etc. ) •
,
These criteria [or ME T treating/exercising patients were
The m e d i cal exerc i se the rapy ap p roac h
•
our reasoning oc c u r th ro u g h ou t bo t h ou r patients. There i s n o t a n artitlcial d i v i sio n between one form o[ reasoning and a n o t h er as understanding the person requires understanding the problem and v i c e ver s a . S i mila rly, o u r commu nicative m a n age me n t direc t ed towa rd ass i s t in g p a t ie n ts to acqu ire h e a lt h ier more constructive perspectives and health behaviours does n ot neces s a r i ly occur separate from o the r man a ge m e n t i n terven tions. Rather. as hi g hl ight e d by the c l i n i c i an here, therapists w i l l continue to ' ge t to know' their p a t i e nt s t h ro u g h o ut their o ngo i n g man agement . often integrating their p syc h o so c i a lly directed management with their physical treatme n t . a spects of
ex a min a ti o n a n d treatment of
p r i o r to treatme n t a t horo u g h assessment is c ar ried out based o n : mu scle tests
1 9 9 3 ; Holten and Torstensen, 1 9 9 1 ; Jacobsen et aL. 1 9 9 2 ) . This has been a ve ry positive and creative ' m ar
the years have mi su nder stood the iVIET concept. bel iev o[ a Ilne ly tun ed / g ra de d exercise programme for p atients u s ing pulleys and other exercise eq u ipment specillcally to stimulate tissue structures locally. This is o n ly a part of the iVIET a p pr o a c h ; some other fundamental prerequisites must be fu lfi lled to be able to apply graded exercises efi1ciently. One of the se is the criteria m ent i o n e d above of being with patients the in g that i t i s the de sig n
whole time they are exercisin g : suppor tin g. motivating,
- specific j o i n t tes ts
ensurin g that t h e
- fu nctio n a l tests
a nd dealin g with kinetic p h o bia Unfortu nately, many
• diagnos i s i s d etermined from the patie n t ' s
.
h i s t ory
and assessment and an o p t i m a l treatment is estab lished • the exerc ise programme i s reassessed and adj uste d wh e n req u i r e d
• a maximum of five patients in a g roup setti n g are treated for 1 ho ur.
patient is coping with the exercising
have focussed too much o n being ' specific ' and in doing so have missing out o n the importance of bei n g to
mo ti v ate
the patient; consequen tly,
present these ther api s ts
do not organize their working d ay and exercise room so
tbat they can work efi1ciently with g rad ed exercises as a treatment. Being present with th e patient in the exercise room also allows the exercises to be graded according to
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• I
C L I N I C A L R EAS O N I N G I N ACTI O N : C A S E S TU D I ES F RO M E X P E RT M A N U A L T H E RA P I STS
the pa t ie n t ' s needs and expectations and ensures that
c a r ried ou t a n d tbat t h e exe r c i s es of t he treatme n t
the q u al i ty of the perform a n c e of the exercises i s opti
pro g ra m m e are reassessed fo r a p pr o p ri a t e nes s a o d
ma l in rel a tion to the pa t ien t s resources.
s t a r ti n g lev e l ( po s i t i o n , wei g h t and repeti t io n s ) . The
'
Other e lements from the MET c ri te ri a are h aving five patients in a group settin g and the th e r a p i s t bein g in the exercise room fo r 1 hour, m a ldn g MET both an e ffi c i en t a n d cost-eHeclive appro a c h . The presence of t h e thera
pist for the whole hou r i s i mpor t a n t to ensure that the patie n t is exerci s ing w i t h the right d osage an d t h a t the patient performs th e exerci s es c or rec tly for m ax i ma l stim u l a tion of the desired fu nclio nal q u al i t i es such as ,
s t ab i li ty, mobi l i ty and coordin a t i o n /ki netic contro l .
re a s s e ss me n t has fo u r steps . F ir s t r ex p l a i n t h e r e a so n for each
1 . Expla n a t i o n .
exercise and the n s h o w the patient how to pcrrorm the exerc i se
.
2. Assessillg repeti tion load. do as m a ny repeti t i o n s
as
Nex t 1 ask t he pa tient to he c a n ma n a ge , w o rk i n g
dyn am ica lly approximately o n e re p et i t i o n every 2 s eco nd s The patie n t is told to s t o p if he is get t i n g .
rea l ly tired or i f t h e exercise i n c reases the s y m p t o m s . If [ see t h a t the p a tie n t is st a r t i n g to work i n a n u n co
M E T exe rc ises
ordinated ma nner. r s t o p t he assessme n t . [ a l s o ask
The M ET e x erci s es ra nge from free ex e r ci s e s o n a mat work i n g agai n s t g r a v ity o n ly to exercises with e lastic bands, sli ng exercise thera py exe rcises with du mbbeUs ,
a nd barbe l l s , to the
use
o r weig h t cu lTs . Ae ro bic exer
cise e q u ipment is the backbone of the MET approac h , u s i n g g l o ba l exercise eq u i pmen t lU(e tre a d mi l ls , s tep machines, row ing m a ch in e s d iffe re n t typ e s o f s t ati o n ,
a ry
b i cyc l e
,
arm
e rgometer s
and
c ross-trai ning
mac h i n es The aerob i c exercise equ ipment is used for .
warm-u p, w here pa t ien t s work [or 1 5-2 0 minu tes before the 1 h ou r of the treatment req uired by the criteri a . Howe ver, g lo ba l aerobic exercises can a lso be i n te g ra ted into the treatme n t , more so for patients w i th
c hronic pain who are de a l i n g with pa i n behavio u r. To be able to grade exercises mo r e loca l ly and to be able to choose comfortable starting pos i t i o n s , the MET exercise eq u ipment co mp r i s e s di fferen t ty pes of bench ( mu l t ip l e p u rpose, an gle and mo b i l izi n g benchs) and p u lley ( s i n gle, double, speed and l atera l p u l leys ) . The s m a ll es t res istance u s i n g t h e p ull ey i s 5 0 0 g , m a k i n g i t poss i b l e t o s t a r t exerc ising a t a very ea rly s t a ge . The we i g h t from the l a teral p uJl ey and the s i n g l e p u l l eys c an be u s e d i n t h e ea rl y s t a g e o f the re ha b i l i ta t io n to de l o a d the body or a p a r t or the body in o rd e r to sti m u l a t e move m e n t , norm a l i z e fu nc ti o n a nd a ss i s t t h e p a t i e n t to cope a n d a c tively h and le their d ysfu n c ti on The p r inc i p l e of d el oad i n g i s a n i m por .
t a n t fea l u re o r MET t h a t ma k es it poss i b l e to s t a r t exerc iSing at a n ea rly s tage of trea tmen t u s i n g a h i g h n u m b e r of rep etiti o n s in sets wo r k i n g t h ro u g h the c o m fortable a v a i l ab l e r a n ge of mo ti o n .
the patient to count and to i ndica te whe n he reac hes six to seve n repetitions i t' he t h inks he wo uld be ab l e to m a n a ge to con t i n u e to at l ea s t 40 repetitio n s . If he a n s we rs 'Ye s , I t hink so but I ' l l have to try ' , be is ,
as ked to do as ma ny repe t i t i o n s as he can manage
beyond 40. If he answers , 'This is too easy or too l i gh t . . n o pro ble m I ca n cer t a i n ly d o more t h a n 40 ' , .
,
I i ncrease the load i ng o f the par ticul ar exerc i s e I f h e .
answers, 'No, t his is too he a v y a n d u nco mfo rt a ble . [ '
ch ange eit her the st a r ti n g posi tio n ( c hoose another exercise) or j u s t change the g rad in g of the exerc i se . 3 , Setting a repe t i t i o n level.
I d e d u c t 2 0 % fro m t h e
pa t ien t s n u mber of repeti t i o ns ( for ty pe r prese n t a '
tio n ) a n d t h e n ro u n d t h i s t o a n e a sy n u m ber t o r em ember ( e . g . if the m a x i m u m i s 40 repe t i tio ns ,
2 0 % i s d e d u c te d , wh i c h i s eig h t givi n g 3 2 , which i s then d ow n to 3 0 ) . For t r e a t me n t p u r poses , the .
patient i s t hen i nstru cted to do t hree sets o r 30 rep etiti o n s w i l h
a
3 0-second break between each set,
u s i n g the pri nc i p le o r in terva l tra i n i n g . For a type III p r ese n ta t i o n , 50% i s ded ucted from the test (40 then b ec o m e s 2 0 ) . 4 . Avoiding ove rload illY,
I f p a tie nt manages t o do
more than 4 0 rep e t i t io n s ( e . g . 5 0- 6 0 ) , I wou l d prob
a bly still wan t the patien t to do o n ly t h ree sets of 3 0 repetitions, co n scio u s l y un der g rad i n g to make s u re that the patient receives a p os i t ive ex perience from the exerc ises. Later 1 wo u l d i n crea s e t h e we i g h t resista nce fo r that p ar t i cu l ar exercise, maldng t he lo a ding mo r e op t im a l wh i l e still kee p in g it at three sets of 3 0 repetitions. If the patient is on ly able to d o
1 0-- 1 5 repeti t i on s d u r i n g t h e assessmen t . i t s u g ges ts
M et h o d o l ogy fo r assessing t h e exe rc i ses
that I h a ve prob ably chosen t he wrong exerc is e or wro n g we i g h t resistance. In that ca s e , r woul d
It is an i m por t a nt part of the MET app r oa c h that the
reassess that exerc ise the nex t time the p a t i en t came
t herap i s t i s present wh i l e the e xerc is es a re bei n g
for treatment. H the patient can o n ly do 1 5 repeti tions
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1 9 A S O FTWARE PRO GRAMMER AND SPORTSMAN WIT H LOW BA C K PAIN AND SC IATI CA
w i t h the easiest exercise ava ilable ,lOd w i t h the l ow
impr o ved
est we i g h t r es i s t a n ce ava i l a ble. I wou ld t h e n start
more fu ncti o n a l by using starting p O S i ti o ns in we ig h t
the p a t i e n t
th ree sets of 10 re p e t i t i o ns . w i th
.
t he exe rc i se s could be regraded a n d made
a
beari ng ( L e . sit t i n g and s t and i n g ) . To ac h i e ve thi s . an
goa l to i n cr e a s e t h e n u m ber or repe titi o ns u n ti l the
exercise prog ra mme was designed c o n s i sti n g of eight to
on
patient co u l d do
three sets o f
te n exercises doing three se t s of 30 re p e titi o n s of
30 repe t itions .
The m e t h o d o l ogy fo r eva l u a t i n g t h e exerc i ses c a n be varied . For ex a m p le. to make s u r e t h i:l t the p a ti e n t c o pes w i t h t h e exerc ise. t he s t a r t i n g pO i n t c a n be c a l c u l Cl tcd b y red u c i n g l h e ' m a x i m u m ' n u m b e r of repe t i t i o n s by 'l ( ) % . i n s t e a d of by l O % . Th i s is be h a v i o u ral t h cr,l py C,I I I
roc u s s i n g
ty p e o f
w h a t t h e p a t ient
pedlln l l . i\ l lO t h e r way ()f g r i: l d i n g t h e e x e rcises is
to ,Isk t h e P, l t i l' ll t
j u st to wo r k l o r
p e r i o d : fo r e X i: l m p l c O l a v ( sec
O il
a
below )
t i mes w i t h
Wi:IS
a
cerlai n time
a s ked t o d o
e x er c i s e
1
I 'o r :; m i n u t es c o n t i n u o u s l y repeated th ree ,I
3 0- (, ( ) seco n d b rea k .
eac h
exercise wit h 30 s e co n d s break between each. The tTeat me n t a l so a i med at i ncreasing the tolerance for loa di n g
so l h a t O l av wou l d be ph y s i c a Uy and psychologica lly stronger
c o m p are d
wi th when t h e treatment bega n .
Through t h e h i g h n u m ber of exe r ci s es repetitions and .
sets in di fferen t s t a r t i ng positions. mu scle i m b a l a nces
and k i n etic control can be impr o ve d and h op e fu l ly nor mal ized . An in1porta n t goa l is t o rega i n task-speci l1c
m o to r improvements a nd regeneration of ti ssue s t r uc
tu res tb rough neu ra l adaptations. T h e g rad i n g of the exercises makes it possible to load affected tissues opti
maUy in the o p tim a l load zone' as we l l as to exercise the '
t i ssue with an Optin1aJ volume of training w i t h i n t h a t zone. resu l ting in re ge ne ra t i o n o f the t issue (Kel sey
a nd
Tyson . 1 9 9 4 ; Torstensen et a l . . 1 9 9 4 ) . For Olav. the a i m of t he treatment i n t h e ea rly ph ase was to ap p ly g r ad e d exercises to treat impai rments l U<e pain and
d e c re a s ed ra n ge of mo tion. n or m al iz e kinetic s tre n g th and end urance
co n trol and increase muscle .
• Initial
assess m e n t
The assessm e n t a n d t r e a tme n t of Olav o ve r l ap p e d i n t h a t t h e mu s c l e/ m o tor con trol assessment was per
U S i n g comforta b l e steu"ling positions i n lyin g and stand
fo r m ed in t he
i ng d e l oa ded postu res. A s Olav's signs and symptoms
con trol with three d i ffe re n t exercises ( exe r c i s e s
Box 1 9 . 1
exercise roo m initially e va l u ati n g Olav ' s 1-3 . see .
Exercise 1 G l ob a l sta b i l i z i ng exercise: s tan ding deloaded s q u atti ng
F i g . 1 9 .3
Exercise 1 .
• T hi s exercise is often used when treating pati e n ts with back pain where the patient fi n d s that deload i n g the s p i n e is comfortable a n d decreases the sympto m s . By attac h i ng a deloading fra me to the lateral p u l l ey. the weigh t from the p u l ley pulls up the deloa d i ng fra me. effectively deloading the patient h o l d i ng on to the fram e (Fig. 1 9. 3 ) . © H o l ten I nstitute and Tom A r i l d Torstensen. with np,"mj,,,,,j,nn
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C LI N I C A L R EASO N I N G I N ACT I O N : C A S E STU D I ES F R O M E X P E RT MAN UA L T H E RA P I STS
Boxes 1 9 . 1 - 1 9 . 3 ) . Not surprisingly, pai n infl uenced his
back pa i n/sci atica T h e st ar t i n g poi nt for t h e exercises
abili ty to pe r fo r m the exerci ses. By tes t i ng these exer
in terms of wei g h ts was defmed at this point too.
.
cises , Olav ' s fear-avoidance beliefs in rela t io n to physi
At t h i s e a rly stage, the focus was on stability and
cal activit}' (as hy pothesized earlier) could be eva lu ated
awareness o f how to stabiliz e the l owe r back, w h i le a t
together with his movement strategies in relation to h i s
the s a me time workin g the upper and lo we r extremities.
Box 1 9. 2
Fig. 1 9.4
Exe rcise 2 Semi-global sta b i l izing exe rcise: supine lying a l ternate a r m swi ng out
Exe rcise 2 .
• T h e starting position of this exe rcise is in a comfortable s u p i ne-lying positi o n . The patient is taught how to stabil ize the back by p u l l ing in the stomach (by th i n king of having a pai r of trousers that are too tight and having to 'd raw-in' the lower abdominal area to b utton the tro users) . A co mforta b l e fi rm pil low can be put under the pati ent's back in the l u m bar area to provide support and something to push agai nst. H o l d i ng one d u m bb e l l i n each hand, the pati ent alternates swinging out the arms, res u lting i n a rotational moment of the trunk. To avoid any movement or rol l ing off the angl e bench, the pati ent must sta b i l ize the back, causing the muscles a ro u n d the torso to wo rk (Fig. 1 9.4).When swinging the right arm, the patie n t is at the same time pushing the right leg down i nto the su rface to give a cou nterforce to aid in fu rth er stabilization of t h e back. © Holten Institute and Tom Ari l d Torstensen, with permission.
Box 1 9. 3
Exe rcise 3 Loca l sta b i l izing exercise: fou r-point kneeling abdom i na l 'd rawing- i n action'
Fig. 1 9.S
Exe rcise 3 .
• This exercise is used as awaren ess tra i n i ng fo r activation of the abdominal muscles a n d , in particular, the transve rsus abdominis (Fig. 1 9. 5 ) . The patient focusses mentally o n the area around the pelvis and the lower abdomen, hopefu l ly fac ilitating the back stabil izers, performing th ree sets of 30 repetitions (Richardson et a I . , 1 999a) . © H olten Institu te a n d To m Ari l d To rstensen. w ith permission.
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1 9 A SO FTWA R E P RO G RA M M E R A N D S P O RT S M A N W I T H LOW BA C K PAI N A N D SCIAT I C A
• Stage
progra mme took. The trea tm e n t time to complete
1
The first slage of O la v ' s exerc ises was car ried o u t in s ix trea t me n ts over 2 weeks u s ing exerc ises 1- 3
(B oxes
1 9 , 1 - 1 9 , 3 ) , Table 1 9 , 1 shows the format that this
these exercises was approximately 30 m i n u tes. The in itial assessment defi ned the wei g h ts that Olav sho u l d u s e i n i tial ly in e a c h exercise ( see Table 1 9 . 1 ) . Exercise 1 was so comfo rtable for Olav th a t he was ab l e to do it conti n u o u s ly for 5 mi nutes. When doing this exercise
Table 1 9 . 1
Exercise chart for stage 1 of the medical
exercise the rapy treatment programme
Olav fe l t that his back and leg pa i n d ecreased sign ift c a n tly Exercise 2 started with 2 kg dumbbells and pro .
gressed later to 3 kg. Full
description Exercise '
Formata
of exercise
• Stage
25 kg. 3 sets of 5 m i n
Box 1 9, 1
The second s tage of O l a v ' s treatment prog ramme was
2
Two 2 kg d u m b b e l l s ,
Box 1 9. 2
c arried out in 10 treatments over 4 weeks (Table 1 9 . 2 ) .
2
A rter the fIrst 3 weeks . Olav was be tter a b le t o tolerate
3 sets o f 3 0
1 repeated
25 kg, S m i n
Box 1 9. 1
3
3 s ets of 3 0
Box 1 9 . 3
1 repeated
25 kg, 5 m i n
Box 1 9 . 1
'Each exercise i s done with a 3 0 second break between sets.
t h e load i n g fro m the exercises a n d consequen tly three additional exercises were i n troduced ( exercises 4- 6 ; Boxes 1 9 . 4- 1 9 . 6 ) u s i n g comfortable starting pos itions i n both sta n d ing ( deloaded ) and ly in g Exercise 4 .
started with 1 0 kg and progressed to 2 5 kg. Over the Box 1 9 .4
Exe rcise 4 G l obal s ta b i l i z i ng exercise: s ta n d i ng p u l l down b e h i n d the neck
E xercise 4.
F i g. 1 9 . 6
• T his is another stabi l izing exercise for the l u m bar spine. The back is kept i n a comfortable and stable position by applying the d rawing in action' of the lower abdominal area and tightening the gluteal muscles. Wo rking the arms by pulling down '
-
behind the neck req u i res both back and abdominal muscles to work togethe r i n syn e rgy (Fig. 1 9.6).The exercise sti m u lates normal muscle balance and kinetidmotor control in wor king the arms and the lower extremity together with the muscles stabilizing the back. Pull ing down behind the neck a n d contracting the extensor muscles of the back results in co contractio n s of the abdominal and pelvic floor muscles, giving a normal s ti mul u s in a functional starting position to -
all structures stabilizing the spi n e By working in a standing starting position, the l ower extremity is also i ntegrated as an .
important factor in retrai n i ng stability of the lower back. © Holten I nstitute and Tom Arild Torstensen, with permission.
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C L I N I C A L R EASO N I N G I N ACT I O N : CAS E STU D I E S F RO M E X P E RT M A N UA L T H E RA P I STS
Tab l e 1 9. 2
Ex e rci s e c h a r t for stage 2 of t h e m e d i c a l exerc i s e therapy treatme n t programme Format
Exercise
F u l l descri pti o n of eJCercise
1 repeated with less weight
20 kg, 5 mi n
Box 1 9. 1
2 progressed
Two 3 k g d u m b be l l s , 3 sets o f 3 0
Box 1 9.2
1 repeate d with l ess we ight
20 kg, 5 m i n
B o x 1 9. 1
3 repeated
3 s ets of 3 0
Box 1 9. 3
4 added
1 0 kg, 3 sets o f 3 0
Box 1 9.4
5 added
1 1 kg, 3 sets o f 3 0
Box 1 9. 5
6 added
2 kg, 3 sets o f 3 0
B o x 1 9. 6
1 re peated with l es s weight
2 0 kg, 5 m i n
Box 1 9. 1
'Each exercise is d o n e with a 30 second break between sets.
Box 1 9.5
E x e r cise 5 Semi-global
Fig. 1 9 .7
stabil izi ng
e xe rc i s e : p rone lying rowing (double e l bow
flexion/extens ion)
Exe rcise 5 .
• The patient l i es prone on the angle bench and perfo rms rowing action, exte n d i ng the s h o u l ders/a rms while h o l d i ng onto a barbel l . By working the u p p e r extre m i ti e s in exte n d i ng the s h o u l ders, muscles in the u pper extremity, s h o u l d e r girdle a n d upper tru n k are a l l worki ng, giving a sti m u l u s for extension of the whole tru n k and activating th e back exte n s i o n muscles ( Fig. 1 9. 7 ) . © H olten I n s ti tute and Tom Arild Torstensen, with permission.
B ox 1 9 .6
Exercise 6 Semi-global sta b i l i z i ng exerc i s e : s u p i n e lying, arm swing back b e h i n d the head and back up
Fig. 1 9 .8
Exe rc ise 6 .
• The patient is lying s u p i n e on the angle bench, applying the 'd rawi ng-in acti o n ' , to sta b i l ize the lower back. By swinging both arms backwa rds, a movement is i n itiated ' rotati ng' the tru n k backwards
i n to
extension. H owever, at
the same time the a b d o m i n a l muscles a re tightened to c o u n teract the momentum i nto extension. thus s tabil izing the l u m ba r s p i n e ( Fig. 1 9 .8) . To progress the exercise, the arms are moved with a h igher speed down and back up.
© Ho lten I nstitute and Tom Ari l d Torstensen, with permission.
Copyrighted Material
1 9 A S O FTWA R E PRO G RA M M E R A N D S P O RT S M A N W I T H LOW BAC K PA I N A N D S C I AT I C A
[o !J owi n g 4 weeks. O l av h ad 1 0 treatments ( t wo or
fo r exercise 2 were i ncreased fro m 2 kg to
th ree a week ) . ea c h t re a t m e n t l a s t i n g approx i ma tely
second ph ase of exerc ises. Olav star ted w i t h 5 - 1 0
3 k g . In t h is
wa s now a l so b r ea k in g a swe a t d u r i n g t h e
m i n u tes work on a s tation a r y b i ke . w h e re he was
tre atme n t . O l av s t i l l c o n t i nued w i t h t he o r ig i n a l three
be gi n n i n g to b re ak a swe a t . In add i tion to th i s O l av
exercises . lWo o f w h i c h were reg r a d e d : exerc ise ] was
wa s do i ng eight exerc ises and t he total treatment time
de l oa d e d from 2 5 k g to 2 0 kg a n d the d um b bell wei g hts
was app rox im ate ly 1 hom and 1 0 min u tes ( Tabl e 1 9 . 2 ) .
1 h o u r. He
.
REASO N I N G D I S C U S S I O N A N D C L I N I CA L REASO N I N G C O M M E N TA RY
D
Please d i scuss briefly your reason i ng behin d the
a c l i n i c a l test o f the fu n c t i o n o f the d ee p abdo m i n a l
specific exercises chosen. including the s ta rting
musc les usi n g
positions used and the dosage p rescri bed.
C h at tan o oga Austra l i a ) did not co rre l a t e w i t h e l ec
an
a i r - l1 l 1 e d press u re b a g ( S t a b i l i z e r
,
,
t ro myog ra p hy (considered the 'gold standard ' of l abora tory a sses s m e n t ) It is also s ti l l unclear how c h a n ge s in
• C linician's answer
.
t hese l o c a l muscles correlate wi th t he p a t i e n t s p a in '
of fu nction for
Because Olav had what I judged to be a ty pe I presenta
experience or w i t h i m p rovem e nt s
tion. the exercises were c hosen i n relation to a pa in
a c tivities of d aily liv i ng a n d retu r n i n g to work .
contingent treatmen t approac h . exercis lng in comfort
In fact we do not completely u n d e rstand wh a t 'stabi
a b l e close to pain- tree star ting pO Siti on s My selection o f
lity' o f tbe back is nor d o we h ave any valid or reliable
starting pos itions for Olav was based o n m y earlier expe
measurements for ' back s tabililY ' . Panj abi ( 1 9 9 2 a ) has
rience with simil ar pa t ie n ts and . or comse. information
suggeste d t hree sys tems for spinal s t a b il i ty : a contro l
.
.
obtai ned (rom Olav throu gh both the s u bject i ve inter
syste m ( n eu ra l) , a passive subsystem ( sp i n al column)
were
and an ac ti ve system (spina l musc les) . Pa njabi ( l 9 9 2 b,
view an d the p llys i cal assessment. The exercises
chosen by asking s im ple questions such as wha t pos i
p. 3 9 4) h a s d e fm ed c li n ical in stab ili ty a s , t\ sign i l1cant
tions and activities ease you r back and leg p a i n a nd wh at
decrease in the capacity of the stabil izi n g system of th e
pOS itions and acti v i t ies in crease yo u r symptoms?
spine to ma in ta i n the in tervertebra l n e u tr al zones
The exerc i ses c h osen a re
c o m bi n a t i o n o f g l o b a l .
within p hys io log i c a l limi ts , which res u l ts in p a i n and
semi -glo b a l . a nd loc a l exercises based on a very s i m
d isability ' . Th is i s still a working hypothesis because we
p l is t i c p h i loso p hy t b a t the back a n d tru n k l in k t h e
have no objective, valid or reliab le way of measuring t he
a
u p p e r an d lower extre m i ties to g e t he r. D u r i n g locomo
neutral zone in vivo. Conse q u e nt ly. the neutral zone and
t io n , we use t h e lower extre m i ty to move trom point A
stability linstabi lity i t sel f become abs t ract p h enom en a
to p oi n t S, a n d the u p per extre mity to pe r form a desired
A fu ndamental q uestio n in relation to t his is how stabil
.
w i t h the h a n d s . T h e u pper a n d lower extre m i t i es
ity / i n stab il i ty correlates ,"lit h a p a ti e n t s pain experience
wo rk tog e th er w i t h t h e tr u n k in co m p lica te d kinetic
an d function. Do these clinical c han ges rea lly c h an ge
c h a in s / p a t ter n s when per for m i n g normal fu nction a l
with improved back stabiJi ty ? We d o not know, but I
task
'
that, if we could measme stability/instabi li ty
activities , a l l i n accord ance w i t h known phy s io logy for
be l ieve
motor con tro l ( Ric hardson et a l . . 1 9 9 9 a , b ; S hu mway
obj ec ti ve ly, one would probab ly fmd that the correl ation
Cook and Woo l l acott 2 0 0 1 a , b ) .
is very weal( , supporting other research findings that
,
T he exercise prog ramme i s a l so b ased o n the know
there is little or no cor rela tio n between organic tissue
ledge that the d eep abdomi n a l and m u l t i fi d u s muscles
structures , pain , impairments and a cti viti es of da ily l iv
a re i mporta n t s t a b i l izi n g stru c t u res o f the back.
ing ( Ka ser et al . , 2 00 1 ; Mannion et al . , 2 00 1 ; Wad dell
Res ults fro m rese arch s u ggest t h a t the cen tra l ner
1 9 8 7; Waddell et aI. , 1 9 8 2 ) . Therefore, stability/ in sta
,
wou ld be an impairment finding meanin g that
vo us system stabil izes the spine by co n tra c t i on of the
bility
ab d om i n a l and multifid u s mu scles in a n t i c i pa t i o n of
some patients wou ld p rob ably become pain free wi th
reactive forces prod u ced by l i m b m ovemen ts ( Hodges
norm a l fu nction still baving an 'unstable' back/spine
and Richardson , 1 9 9 7) . However, in an i nvestigation of
.
However, we all do agree that it is im portant to h ave
t he contri bution of tra nsve r s u s abd o m i n i s to sp i n a l
a strong a n d s t a b l e back, a n d that
s t abi l i ty d u ring l i mb move ments ( Hodges et a l . , 1 9 9 6 ) ,
the stabi l i ty of the back t h ro u gh exercise therapy is
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a
n o r mal iz a ti o n of
C L I N I C A L R EASO N I N G I N ACT I O N : C A S E STU D I ES FROM E X P E RT M A N UA L TH E R A P I STS
an important p a r t of the tre a tm e n t (or patients with
doing stcmdin g deloaded squ atting for 10 minutes. and
low back p a in ; this i s the MET appro a c h .
i t is easing the back and leg pain . the stimu lus from
The c hoice o f exercises a nd their g r a d i n g i n MET
the exercise is considered a ppropriate and typica lly
is also based on research rega r d i n g the force c losure
contri butes to normalizing fu nction. One can hypo
of the sacroil i a c j o i n t and its importance for stabil iz
thesize that during the deloaded squ a tting exercise
i n g the back a n d pelvis. In trus regar d . fo u r muscles
intermi ttent compression is occurring in the l u mbar
are b e l ieved to be espec i a l ly impo r t a n t : the erector
spine, thereby i ncreasing circ u l ation to a l l struc tures .
s p i n a e . glu teus maximu s . l a tissimus dorsi a n d b iceps
in cl udi n g those causing the pain. Another poss i b le
femor i s . It i s proposed that knowledge o f the coupl i n g
mechanism that may contribu te to the easing of symp
mechanisms be tween the s p i n e . pelv i s . legs a n d a r m s
toms is the stimul ation of mechan oreceptors i n mus
i s essential to understand dysfu nction of the h u m a n
cles . tendons, joi nts a nd o ther structures in the upper
locomotor syste m . particul arly t h e lower back . where
ex tremities . the tru nk and the lower extrem i ties. Psy
three mu scle slings (a l o n g i tudi n a l and two oblique)
chological ly. when the patient nnds the exercise com
c a n be activated for optimal stab i l i ty ( S n ij d e r s e t a l . .
lor t a b le and easing symptoms. there will proba b ly a l so
1 9 9 3 ; V le e m i n g e t a l . . 1 9 9 7 ) .
be a cognitive reaction to the pain stimu lus, res ulti ng in
From the i nformation above. o n e c a n conclude that
a fur ther decrease in the pain experienced .
it i s j u s t as impo r t a n t to involve the upper extremity a s
In t h i s e a rly p h ase of the treatme nt. the focus was
i t i s the tra nsversus abdominis m u s c l e locally. a n d i t is
on stabil ity of th e lumbar spine, regardless o f the start
j us t as i mportant to i nvolve the lower ex tremity as i t is
ing positio n , w i th the a im of s t i m u l a ting the stab i l
the multifidus muscles locally when designing a n exer
izin g structures aro u nd t h e b ack . T h e dosage chosen
cise programme for a patient with low back pain /dys
(Table 1 9 . 2 ) is usually enough for many p a t i e n ts to
functi o n . According to theories in movemen t science.
break a sweat. wo rking the upper extrem i ty together
the hu man body organ izes a l l movement pattern s i n
w i t h the lower ex tremity and s t i m u l a t i n g core stabi
rel ation t o task-specific activities and moves i n complex
lization of the spine. thus norm a l i zi n g k i netic con t ro l .
kinetic patterns involving complex muscle synergies .
A nother reason for focussi ng on stab ility a t this stage
The aim of the exercise programme is to make the back
for O l av is that mobilizing wil l u s u a l ly i n crease symp
as ' functional ' a s possible. ultimately doing fu nction a l
toms . When foc u s s i n g on stab i l i ty, I can o n ly use my
activities l ike lifti ng. p u s hing and pulling.
eyes to evaluate the q u a l i ty of the perform a nce o f lhe
W h i le simple questions such as ' What positions
exercise and palpati n g fi ngers to make s ure that the
increase or decrease your symptoms?' and ' What is your
patie n t is keeping the back s t a b l e and not movi n g
preferred direction of movement? ' assist in determining
i t . Then , o n e m u s t s t i ll a s sume that t h e muscles and
fi n d in g t he specific
l igaments keeping the back stable a re work i n g as they
dosage is based on trial and error from e arlier experi
appropriate
star tin g
positions,
shou ld do. However, research has sh own that it i s
ence with using this method . and trial and error wi t h
diffi cult t o palpate the contraction of the transversus
e a c h ind ividual patient. The method of assessing the
abdomi n i s and that there is poor corre l a t i o n betwee n
appropriateness and starting level (posi tion . weight and
palpation a n d the gold sta ndard of rea l - time u l tra
repetitions) for each exercise is described in detail above,
sou nd ima g i n g (Ha u g Da h l . 2 00 0 ) .
under Methodo logy for assessing the exerc ises (p. 2 9 0 )
.
In general . the a im is to end up ""rith seven to n ine exer
The philosophy is that there is n o t one specific exer cise that is on its own su fficien t . rather it is the sum of all
cises, but this may tal{e 2 to 3 weeks to acrueve [or some
the exercises and aJJ the repetitions performed that is
patients . In the early phase, the aim is to familiarize the
important. In fact. I could prob ably have chosen three or
patient with the exercises while working on any nega
even [our other stabilizing exercises , so this is a prag
tive perceptions and beliefs about dysfunction in rela
matic approach. not dogmatic. where the only limita
tion to physical activity. The early phase, therefore, for
tion is the therapist's experience and imagination.
most p a tients involves beh avioural therapy. Later, the grading is increased according to ordinary exercise prinCiples described in the work physiology literature . One exception is the d e loaded sq uattin g exercise, where the patient tries the exercise in itially for 1 min ute. then [or 2-5 minu tes a nd then if possi b le for 1 0 minutes. This is tri a l and error; i [ the patient tolerates
• C l i n i cal
reas o n i n g c o m m e n tary
M a n u al therapists are rightfu l ly bei n g increasin gly challenged
as
to wh ether t h e i r prac t ice is ' evidence
based ' . This is also
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a
req u i reme n t of s k i l led c l i n i c a l
1 9 A S O FTWA R E P RO G R A M M E R A N D S PO RT S M A N W I T H LOW BAC K PA I N A N D S C I AT I C A
re asoning. However. t h i s doe� n o t mean t h a t thera
is based on ski lled. critical and rel1ective reaso ning.
pists shou l d be restrict e d to o n ly us i n g wh at has
Th e reaso n i n g o f this expert c l i n i c i a n i s clearly
been 'proven ' throug h randomized controlled tri als.
based on both rese a r c h - b a se d and experience-based
as to suggest t. h is wou l d not on ly le ave us w ith l i ttle
e v i d en c e .
to
use
but also limit o u r d is c ove r y of new and better
a p p ro a c hes
.
M a n u a l ther a pist s must draw o n the
The broader expe ri m e nta l evidence. basic
science m u scle work / phys io logy clinical experience and
this
e v i de n c e .
prior
p a ti e nt s p a rti c u l a r '
fu l l r a n ge of av a i l a b l e evidence from c l i n ic a l trials
presentation h ave all g u i d e d h i s l o gi c a l strategies for
and the assoc i a ted systematic reviews t h r o u g h to
sel ec tion . dosage a n d pro g re ss i o n of exercises .
experience-based evidence. p roV i d i ng th e exp e r ie n ce
so that after 4 weeks Olav wa s d o i n g a l l s i x differe n t
Asse ssing early progression
exerc ises with progress ion ( i . e. reg rad i n g ) of two
D u ring the I1 r s t week of the treatme n t . o n ly th ree o u t
of t h e six exe rcises we r e i n troduced (exercises 1-3 . w ith th ree repeats of exerc ise 1 : Ta ble 1 9 . 1 ) . These th ree exercises we r e the most comfortable for Ol av.
The aim of the exerc ises was to get symptom control with the l o a d i n g i nduced thro u g h the exe rcises. To
meet th is a i m , comfortable starting p o si t io n s were cho sen . work i n g t h rou gh a comfortable range of motio n . and with ei t h er gravity assistance i resistance or w i t h wei g hts re sis ting or assisti n g the moveme nt. Fo l lowi n g close commLmication wi t h the patient. more exercises were i ntroduced ove r the next 2 weeks
exercises (Table 1 9 . 2 ) . The exercises were e v a l u ated u s i n g the methods d escri bed above u nder Methodology
for assessing the exercises (p, 2 9 0 ) . A l l e igh t exercises performed by O lav focussed on d y n a mi c muscu l a r work , doing o n e repe tition every 2 seconds, a n d u s i n g starting p o s i t i o n s that were comfo r table b y u n load i n g the spi ne. The em p h as i s was on coord i nation a n d sta b i l i ty of the l umb ar spine. B y wo rk i n g t h e upper extremity together w i th the tru nk and the lower extremity. normal muscle b a l a nce is induce d . fac i l i tating overflow to t h e core-stab i l izin g mu scles o f the tr u n k and lower back.
REASO N I N G D I S C U S S I O N AN D C L I N I CAL REASO N I N G C O M M E N TA RY
II
However. there i s today n o h a rd scienti fic evidence
The n u m b e r of repeti tio n s of exercises you use are greater th an what some thera p i s ts
r e gardi n g what type of exercise or dosage is best for
wo u l d ge n e ra l l y p re s c r i b e . Can you d i s c u s s
m a n a g i n g back p a i n (Faa s , 1 9 9 6 ; van Tulder et a l . .
the phys i o logical a n d psyc h o l ogical bas is
2 0 0 0 ) . There i s an increa S i n g body o r knowled ge that
u n d e rp i n n i ng these large n u m bers of
i n d ica tes aerob i c exercise i s assoc i a ted with be tter
re petiti o n s ?
clinical resu l ts (Man n i o n e t a I . , 1 9 9 9 ) and that, given
the general lack of tre atment specific i ty w i th aerobic
• C l i n ician's The main
aim
answe r
exercise, the main effects are l i kely the re s u l t of some
at this early stage was to malce exercis
ing a p osi tive experience [or O lav. a n d to mo tivate him to start exerc ising and stay active. Consequently, undergrad iog was employed to help to ensure that exerci sing was a p os i t i ve experience a n d usefu l as a posi tive copi n g s tra tegy. U n d er g ra d i n g at the begi n
'central ' modu l a ti o n , p e r h a p s c a u sed by changing the pa tie n t ' s perceptio n s a n d bel iefs ( M a n n i o n et a l . . 1 9 9 9 ) . The Cochra ne Collaboration Back Review G ro u p (van Tu lder et a l . . 2 0 0 0 . p. 2 7 9 5 ) concluded that there is r e a l l y n o documen tati o n t h at exercise th e ra py i s any better than traditional physiotherapy:
n i ng of t h e treatm e n t also allows a hi gher n u mber of
T here is strong evidence that exercise t hera py i s
repetitions . which c a n produce i n creased circula tion
m o r e e ffective t h a n u s u a l c a re b y G e n e r a l Prac
to a l l tissues and struct ures ; e n h ance local a n d gen
ti tioners (GPs) a n d that exerc ise therapy and
era l end urance: racil itate n e u ro m u s c u l a r a dap ta t io n s
conventio n a l physiotherapy ( c o n sisti n g of hot
( S ale, 1 9 8 8 . 1 9 9 2 ) , kin e t i c / mo t o r control and mus
packs. massage, traction. mobilisation. shor twave
cle balance; and mod i fy the patie n t ' s p a i n .
di athermy.
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u l trasou n d ,
stretch i n g ,
l1e x i b i l i ty
C L I N I C A L R EAS O N I N G I N ACTI O N : C A S E STU D I E S F R O M E X P E RT M A N UA L T H E RA P I STS
• psychosoci a l go a l s :
a n d co-ord i n a t i o n exerc i s e s . electrotherapy) a re
sti mu l a te a n act ive c o p i ng st rategy
equally c lTective. H oweve r. it s ti l l is u n c lear whether exe r c i se t hera py is m ore effective tha n
s t i m u l ate empowerment
i n a ctive treatme n t [or c h ro n i c low b a ck p a i n .
decrease fe a r- avo i d a n ce b e l i e rs reg a rd i n g p hys
a n d i t a l so rema i ns u nc l e a r w h e ther a n y s pe ci fi c
ica l ac t i v i ty
type o f exercise (flex i o n . ex te n s i o n . or s tre n g t h
decrease a nx iety and d ep ress i o n
e n i n g exer c is es ) is more e ffective t h a n a nother.
i m prove s l eep p a t te r n s retu r n t o work
Randomized contro lled trials have shown that MET i s erfective for patien ts (Torstensen et a l
. .
with chro n i c
g i ve a ne w u n dersta n d i n g regard i n g w h a t
l ow back pain
1 9 9 8 ) and for pa t i ents a fter di scec
promote pati e n t respon s i b i l ity fo r m a n a ge
tomy (Dan ielsen et a1. . 2 0(0). Even thoug h there are
ment and perso n a l h e a l t h
d i ve rg e n t opi nions about what exercises to c hoose. when working with patients o n
an
(e.g. O ' S u l l ivan et al
..
1 9 9 7 ) a nd when a combination
of l oc a l . semi-global and global exercises are used ( Tors tensen. 1 9 9 3 . 1 9 9 8 ; Tors tensen et a 1.. 1 9 9 9 ) . T h e theoreti c a l ration a le fo r ask i n g O l av t o u s e
a
h i g h n u m be r of exercises a nd a h igh n u m ber of repe titions i n sets i s t h a t i t w i ll p rov i de a go od s ti m u l u s to n o rma l ize fu n c t i o n o n an orga n i c l eve l (of d ifferent t i s s u e structures ) . i n c re a s e range of motion a nd muscle s trength ( normalize function on an impairment leve l ) . normalize fu n c tion i n rela tion to d i fferen t d a i ly a c t i v i ties ( o n a n i n d ividual l e ve l . i . e . disabi lity ) . a n d . I1 n a l l y, h e l p h i m to p a r t i c i pa te i n d i ffe r e n t social activ ities. which is fu nda mental ror l ivi n g a whole l i fe ( fu nc t i o n on
a
d ecrease re l i a n c e o n med i c a t i o n .
in d ivid u al level . effI
cacy h a s been demonstrated w i th local specific exercises
soc i e t a l leve l . i . e . h a n d i c a p ; Woo d . 1 9 8 0 ) .
T h e fo l l owi n g physiologi c a l . n e u rophysiolog i c a l
a n d psychosocial goa ls are s o u g h t t hro u g h this level of exercise t h era py :
C <l 1l
be d o ne to i mprove the co n d i ti o n
Through the
a pp l i c at i on
of
a
h i g h n u m ber of varied
exercises. one of the a i ms i s t o i ncrease local a nd gen e r a l
end u rance
( s t i m u l a te
the
cardiovascular
s y s tem) . as wel l as i nc rease muscle stren g t h . M u s c l e s tre n g t h w i l l increase when t h e p a i n decreases a n d the pallent is l e s s scared a n d more motivated to do stronger musc u l ar con trac t i o n s . O v e r t h e y e a r s I h ave mel m a ny therapists t h rou g h courses/semi nars wh ere I h ave been t.each i n g lvl ET. At the start of t h e c o u r se. T often ask the partic i p a n ts how m a ny exercises . s e t s a n d number of repeti tions i n each set t h ey apply to i n cre ase m u scle s tren g th in
p a ti ents with p a i n and m ove me n t dysfu n ction . T h e a nswer I get most t im es is 7- 1 0 repeti t i o n s . two sels
a nd fo u r to six exerc ises. T h i s is very i n teres t i n g as it i s , of cou rse. true fo r h e a lthy i n d i vi d u als However. .
it
al
s o shows that we do not ta ke i n t o co ns ide ra ti on
the ract t h a t patie nts h ave pain. decreased r a n ge or
• p hys i ologi c a l goa l s :
m o ti on . a nd maybe a fea r o f movi n g . a n d t h a t we
d e crease p a i n
have to d e a l w i t h these issues before we c an p u t a
d ecrease s we l l ing
p a tien t s traig h t i n to
s timu l a te rege n eration of tissue s tr u c tures
prog ramme . In fac t . we c a n not t r a i n muscle stre n g th
a
ty pic a l
strength
tra i ni n g
i n crease r a n ge of mo t i o n
i n p a tien ts who experi e n c e pa i n . a n d i t is o nly when
i ncrease loc a l a n d glo b a l e n d u rance
th ey are sy mptom fre e with n o r m a l run c tion th a t this
i n crease local a nd global muscle stre n g th
becomes possi b l e . The effect or pain and s wel l i n g on
increase the p hy s i o l ogical tolerance fo r l o a d i n g
muscular func tio n i s wel l docu mented ( B e n -Yishay
( local a n d global)
et a l . . 1 9 9 4 : Brox et a I . , 1 9 9 5 : Roe. 2 0 0 0 : Solem
make the p a tie n t swe a t . stimul a t i n g the body ' s
Bertort et a l . . 1 9 9 6 : S tokes and Yo ung. 1 9 8 4 ) . but
own pain-in hibi t ing substances (e.g. endorphins)
such knowledge is o ften not fu l ly i ntegra ted i n to the te a c h i n g o f exercise therapy in m a nu a l therapy a n d
• neurophysio logical goa l s :
decrease p a i n
other c o u r s e s . Conseq u e n tly, therapists t h i n k they
improve coord i n ation. motor c o n trol/ki netic
c a n p u t p a tients w i t h p a i n and dy s fu n ction i n to a
control
straig h tforward exerc ise prog r a mm e with rew repeti
tions; this may be one reason why the n u mber of' rep
i mprove stabil i ty i n crease
musc l e
adapta t i on s)
strength
( n e u romusc u l a r
eti tions or exercises used in MET i s g reater than some thera pists wo u ld genera l ly prescribe.
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1 9 A S O FTWA R E P RO G R A M M E R A N D S P O RT S M A N W I T H LOW BAC K PA I N A N D S C I AT I C A
M u s c l e s t r e n gt h is a n a b s t r a c t phenome n o n i n ll u enced b y the p a t i e n t ' s motiv a t i o n t o c o n tr a c t h i s / h e r
repeti t i o n s ) i n sets m u s t be used to i n crease m u scle s tren g t h fu r t her.
muscles w i t h the pos s i b l e res u l t o f i n c r eased p a i n
A n i m p o r ta n t (J i m o f t h e exerc i s e prog ram m e fo r
a nd i nj u ry t o t i ssue structures, F u r ther. when test i n g
O l av was a l s o to o b t a i n rege n e ra t i o n of d i ffe re n t tis
muscle fu nc t i o n / s t r e n g t h i n a Cybexll3iodex m ac h ine.
s ue s t r u c t u re s . T h e re i s good e v i d en c e that l o ad i n g
the n u m bers corn i ng o u t o f the m a c h i n e a re not an
t h ro u g h exerc i s e s is t h e o p t i m a l s t i m u l u s for r e gen er
objec tive measure o f muscle s trength . peak torq u e . totetl
ation of musc le. bone. fas c ia, ten d o n s a n d n e r ves
wo r k . or wh a tever m u scle fu n c t i o n we w a n t to meas
( B a i ley
u re ; rather. they a re an i n te g ra ted m e a s u re o f p a i n .
Jii r v i n e n a n d Le h t o . 1 9 9 3 ; Ka n n u s e t a l
and
McC u l l o c h .
1 990;
He n dri c ks .
1995;
1 992a.b;
. .
m ot iv a t i on coping. somatizati o n . an x ie ty, de press i on .
Maffu l l i a n d K i n g . 1 9 9 2 ; M o l tz el a l . . 1 9 9 3 ; T i p to n
fe a r- a void a nce beliefs . k i n e t i c p h o b i a . a n d t h e el'fect
e t a l . . 1 9 7 5 ) , T h e ex e rc i s es ma ke the tissues stron ger.
.
these varia b l es have o n an i n d i v i d u a l s w i l l i ngn ess to
i n cre a s i n g t h e i r tol era nce fo r l o a d i n g , and c o n d i t i o n
perfo rm , Th i s v iew h a s been p r o m u l ga ted by Newton
t h e person w i t b b a c k p a i n to perfo r m . o r a t l e a s t cope
'
et a l . ( 1 9 9 3 ) . w h o conclude that ' is o ki n etic tes t i n g of
better w i t h . h e avy work such as l ift i n g . p u s h i n g and
patien ts with chronic low back pain s ho u l d be re ga rded
p u l l i n g d i ffere n t o bj e c t s . Through t h e exe rci ses a n d
as an ind i c a t o r o f the l e vel of p e rfor m a n c e at the t i me
repe t i t io n s . t h e tissues a r e biomec h a n ic a l ly loaded .
of test i n g a n d more as
s t i mulating rege n e r a t i o n i n t h e s t ress l i ne s o r the
a
a
psyc ho-phy s i c a l tes t t h a n
v a l i d test or measure of true m uscle ca paci ty
as
' ,
A nother reason fo r Olav pe rfo r m i n g the h i g h n u m
l o a d i n g . Thus the rege n eration o f the tissue is fu nc tion a l because it h a ppe n s w i th i n n o r m al moveme n t
ber of sets a n d repetitions is to st i mu l a te improved
patterns p e r fo r m e d i n a coord i n a ted
n euromuscu l a r con trol ( coord i n ation. ki n etic con trol ) .
a n d Tyso n . 1 9 9 4 ; To rstensen et al . . 1 9 9 4 ) .
m a n n er
(Kel sey
T h i s i s a c h i eved by ac t i v at i n g n euromuscu lar a d a p t a
The MET progra mm e for Ola v was a lso designed to
tions ( Mo r i ta n i . 1 9 9 2 ; S a le . 1 9 8 8 , 1 9 9 2 ; S t a ro n e t a l . .
i n c rease local endurance a n d more g l o b a l en d u ra nce.
1 9 94) such as;
Increased local and gl obal e n d urance is i mportu nt in
• i n c r ea s e d acti v i ty i n t h e cen tra l n e r vo u s system • i m proved sy n c h ronization o f m o t o r u n its
that a s it improves there is gene r a l ly a cor respondi n g decrease in the pa i n e xperi e n ced . an i ncrea sed ra nge of motio n . a n inc rease in gen era l and loc a l circ u l a tion
• decrease of ne u ro lo gica l i n h i biti n g rel1exes
( t h u s increas ing metabolism a n d regeneratio n an d
• i n h i b i tio n of G o l g i te n d o n orga n s
incre a s in g local conce n trations of effectors s uc h
• i n c reased i n h i b i ti o n of an ta gon i s t muscles
as
bradykin i n ) cmd a pos itive effect on psychological/cogni
• i n c rea sed activation of synergy m uscles • i mproved i nter p l a y (co-co n trac t i o n s ) of synergy muscles • i n h i b i t i o n of ne u r o l og ica l p ro t ecti v e mec h a n i sms • m o re e ffec tive n eu rolog i c a l rec r u i tm e n t pa tter n s • i m p rove d motor neuron activation l evel .
tive componen ts; the last ["allows with t he positive expe rience of be in g able to do so many exercises a nd so many repetitions and breaking
a
sweat, somet h in g many
patients never experience. I n creasi n g th e endurance and exerc ising to the po int of breald n g a sweat d u ri ng the treatmen t will h o pefully also release e n dorph ins
T here is a l so evidence t h a t t h e i n crease i n mu scle
.
The h i g h n u m be r of e xerci ses i n sets , e n d i n g u p
s tre n g th d u ri n g th e fl r s l 4-6 w ee ks of e x erci s i ng in
w i t h more t h a n 1 0 0 0 re petiti o n s d u r i n g e a c h treat
u ntr a i ne d i ndividuals is main ly a res u l t of these
m e n t . was also a i med a t decreasing O l av ' s p a i n a s
An increase in m u scle
s timu l ati n g mech a n i cal receptors i n m usc le s ten d o n s ,
fibre d i a meter as the re ason for increased m u s c l e
n e u romusc u l a r
a d a pa ti o n s .
j O i n t c a p s u l e s a n d many other tissue structures c a n
strength occurs l a ter. In MET,
block off the ' p a i n ga te ' .
an
en d ura nce s t i mulus
w i t h a t least 1 0 00 repeti t i o n s perfor med d ur i n g e a c h trea tm e n t g i ves
an
i n crease
in
mu scle s treng th
.
Pos i tive psyc h o logic a l re a c t io n s ( i , e . O lav experi enci n g th a t he actua l ly ca n use his b ody a n d that he
th ro u g h a decrease in p a i n ; an i ncre ase in motiva
in fac t can do q u i te
tion to c o ntract the m u scles, generating a greater
lo adi n g the spi n e and the bo d y Th ere is also the poten
fo rce ; a n d stimu lation a n d norma lization of ne u ro
tial for p a i n to d ecrease a s a resu l t of the i n crea sed
a
lot) d e c rease the fea r of m o v i ng/ ,
patient
k n ow led ge gai ned from ex pe r i e n c i n g what exercises
s t ra i g h tforw a rd stren gth
are co mfor table, what ranges of motion are accepta ble
tra i n ing prog ramme w i th less repetitions (six to n i n e
to wo rk in a n d that a patient is a b l e to bre a k a sweat
m u sc u l a r
a d apt a ti on s
,
becomes sy mptom free.
La ter, a
when
the
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I I
CLINICAL REASONING IN ACTION : CAS E STUD IES FRO M EXP E RT M A N U A L T H E RAPI STS
when t h e exerc ises are appropriately g r ad e d accord
ballistic movements, stimu lating increased range of
ing to s i g n s and sympto m s . By h a ving a ra nge of
moti o n . T hro u g h the exercises, coordination and kinetic
exercises with comfortable starting positi o n s , wor k i n g
control is i m prove d which aJso stimu lates i ncreased
coordin a ted throu g h the comfortable range o f motio n ,
range of motio n . Muscle
w i t h a h i g h number of repetitio ns in sets ( more t h a n a
aJso improved through the exercises . Muscle strength
1 000 re petitions in total) , the stabilizi ng and dy n amic
general ly increases as the pain decreases and the patient
,
stren gt h and endurance
are
struc tures o f the back plu s the upper and lower extrem
becomes less afraid of actively contracting th e muscles.
i ties are worked .
The increase i n muscle s tre ngt h and end urance, in turn,
T h r o u g h the l i m b i c syste m , the p a t i e n t m ay also exper i e n c e less pain thr o u g h the sec u r i ty and motiv
fu rther en hances the gains in r ange of motion. Ho pefully a l l these different effects of MET wil l a ss i s t
ation provided by t he therapi s t ' s presence a n d support.
Olav to resume normal d ai ly activities
It i s i mporta n t that patients are c o m fo r table abou t
Wi th th is improveme nt, the exercise star ting positions
d o i ng t h e r i g h t t h i n g a n d feel t h at t h e reactions fro m
are cha nge d to more fu nctio n a l posi t i o n s in si tt i n g and
exercisi n g a re not d a n gerous b u t n o r ma l .
as
he i mp roves
.
standing weight-bearin g positions. According to theor
O lav h a d a d e c reased range of motion a n d a n o ther
ies of move m e n t science, d a ily activities s ho u l d be
goa l with the MET prog ramme was to normalize this
improved by work i ng i n functio n a l a n d v aried starting
i m p airme n t . R a n ge of motion s h o u l d i ncrease as pain
positions and moveme nt pa tter n s .
a n d fe a r o f movi ng decreases. This i n crease i n range
T h e MET progra mme w i l l i n c r e ase Olav's physica l
probably results fro m b o t h neurom uscu l a r v a r i a bles
a n d psychological tolerance fo r loadi ng-his b a c k will
( e . g . norm a lizing the i n te r p l ay be tween ago n i s t a nd
become 'stronger' and more ' d u rable'-so that he is
a n t ago n i s t-m u s c l e synergies in p hysiolog ical
variables
(e.g.
kine tic c h a i ns) and
s tretching
effect
on
muscu lar tissue/coll age n ) . The exercises are a form of
I
•
better a b le to tolerate his wor k and daily demands. He should be.c ome more coordinated, improving h is
Cognitive therapy
Tissue therapy Regenerat i o n of the col lagen tissue t h ro u g h biomech
�
---"
_ _
a n i cal load i n g and
I
i n c reased c i rc u l a t i o n
I
Back p a i n and rad i c u l a r pain
I • •
•
1
•
c hange pain
•
motivation for
behav i o u r
•
•
stay i n g ac t i ve active coping st rategy
Pain therapy release of endorp h i n s
•
s t i m u lation of mec h
•
i n c rease c i rc u l a t i o n
an oreceptors to n o r m a l i z e homeostasis in t h e t i ssue •
being active coping with p a i n
C i rculation a n d
Neuromuscular
Respiratory Therapy
ki netic control motor contol
•
m u s c l e strength
I Fig. 1 9 . 9
lifting
tec h n i q ues and other rele van t wo rking tec h n iques,
•
heart and c i rc u l a t i o n system (lower heartbeat) respiratory system ( i n c rease
V02 max)
S u mmary of the goa l s of O l av's exercise progra m m e . The aim was to act as
'tiss ue therapy', ' n e u ro m u s c u l a r t h e ra py' and 'cogni tive the rapy'.
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1 9 A S O FTWA R E P RO G RA M M E R A N D S P O RT S M A N W I T H LOW BACK PA I N A N D S C I AT I C A
w h i c h wi l l reduce t h e risk of fu rther b a c k p a i n . Hopefu l ly, t h e exercise prog ramme w i l l give O l av a new and better understa n d i n g of what back p a i n i s and w h a t he h i m self can do t o fu nction n ormally i n l i fe. Maybe he w i l l be be tter a b l e t o s e e t h e connection between work, rest and physic a l activ ity. These c h a n ges may be impor t a n t regardi ng return to wo rk , but o t her factors may well b e more i mportant, s u c h as work s a tisraction. control of own work s i tu a ti o n , relation s h ip with employer a nd colleagues a t work , content o f wo rk, work l o a d , etc. (Torstens e n , Olav,
as
with each patient,
2 00 1 ) . However,
must be individu ally screened
a n d assessed i n rel ation to all the d i fferent vari a b l e s , r a n g i n g from phYSical t o psychosoc i a l . in rel a tion t o r e t u r n to work. A s u m m ary of t h e go a l s o f O l av ' s exercise prog ramme i s i ll u s trated i n F i g u re
19.9.
nation o r propos it"i o n a l rese arch- v a l i d a ted evi dence and the c 1 in i c i a n ' s perso n a l c r a ft k n owl edge. l i nked to what i s ' kn ow n ' from the available
instantiated through critic a l reflec
research b u t tive
reason i n g
from
Where t h e n ovice
prior
clinical
e i t her u n p roven c l a i m s of other professio n a ls or the latest rese arch fi ndings, experts w i l l o perate o n a
higher level. wei g h i n g a l l forms o f evidence.
Importan tly,
as
i l l u s tra t ed here,
the expert will also
recognize the l i m itations o f ava ilable evidence. a p plyi n g
( physiologic a l ly
and
cogni tive-behav
iourally) what evidence i s ava i l able with consider ation for each patien t ' s i n d ividual and not j ust
as
a
prese n t a tion
rec ipe. T h i s is impressively
demon strated here with the c l i n i c i a n ' s use or physiologica l . neu rophys iologi c a l a n d psych oso
• C l i nical reaso n i ng co m mentary
cial evidence combined with his own reflect ive
Proced ural reaso n i n g to select and progress m a n
experience-based evidence to effect
u a l t herapy treatment s h o u l d be based o n
of c h a n ges through h i s treatme n t .
a
experience.
is l i kely to be overly b i a sed by
c o m bi -
a
broad range
• Stage 3 4 weeks, a n d a total o f 1 2 treatments , O l a v h a d started t o improve. His p a i n d ecreased a n d he toler
After
ated a greater loading both at work and at home. The
MET programme was a l so changed accord i n g ly, by i n creas i n g the loadi ng and a lso by c h a n g i n g the start i n g positions from standing delo aded a n d lyi n g , to stand i n g l oaded a nd s i tt i n g starti n g positions .
Tab l e 1 9 . 3
The third progression of Olav ' s exerc i ses was c a r ried out
i n 1 6 tre atments over 7 weeks (Table 1 9 . 3 ) . The
aim of this th ird prog ression was to increase fu rther Olav ' s tol erance for l o a d i n g and work i n g the spine in fl ex i o n a nd extension. Rotatio n al exercises were a l so introduced, work i n g i n a c r a n ial to c a u d a l d i rection of the spine. These new exercises , in Boxes
7-1 3 , are described 1 9 . 7-1 9 . 1 3 . In the MET a pproach , t r u n k
Exercise c h a r t for stage 3 o f the medical exe rc i s e therapy treatment p rogra m m e
F u l l descri p tion of exe rcise
Exercise
Form ata
1 rep e a ted
20 kg, 5 m i n ; increased ove r 4 weeks to 1 5
7 added
3 sets of 1 5 ; i nc reased ove r 4 weeks t o 3 sets of 25
4 p rog ress e d
20
kg, 3
kg, 5 m i n
Box 1 9 . 1 Box 1 9 . 7
s e t s of 30; increased ove r 4 weeks to
Box 1 9 .4
25 kg, 3 sets of 30 8 added (p rogressed
3 sets of 1 5; increased ove r 4 weeks to 3 sets of 25
Boxes 1 9.8 and 1 9. 9
to exercise 9 ) 1 0 added
15
kg. 3
sets o f 30; increased over 4 weeks t o 20 k g
,
Box 1 9 . 1 0
3 s ets of 3 0 1 1 added
4 kg, 3 sets o f 3 0 ; i n c reased over 4 weeks t o 6 kg, 3 s e ts o f 3 0
Box 1 9. 1 1
( n o rest between 30 rotations to left a n d 30 to right) 1 2 added
2 kg , 3 sets of 3 0 ; increased over 4 weeks to 4 kg, 3 sets of 3 0
Box 1 9 . 1 2
1 3 added
4 kg, 3 sets of 3 0 ; i n c reased ove r 4 weeks to 6 kg , 3 s ets of 3 0
Box 1 9.1 3
'Each exercise is done with a 30 second b reak between sets.
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C L I N I C A L REAS O N I N G I N ACTI O N : C A S E STU D I E S F R O M E X P E RT M A N UA L T H E RA P I STS
Box 1 9. 7
Fig. 1 9 . 1 0
Exerc i s e 7 S e m i -globa l exercise: m o b i l i z i n g i n a cra n i a l-ca u d a l d i recti o n
Exercise 7 .
• T h i s a b d o m i n a l exerci s e is eas i e r to do lying at an i nc l i n e than lying ho rizonta l ( F ig. 1 9 . 1 0). H owever, if the i ncline is i n c reased too m u c h , so that the patient is moving towa rds a sitting positi o n , sym ptoms u s ua l ly i n c rease. The exe rcise i s started by applying the ' d rawing-in action' of the l ower abdominal wal l , thus sta b i l izing the bac k. and then fl exing the tru n k i n a cran ial-ca udal d i rection, wo rking th rough a comforta b l e range of moti o n . In the early phase it is i m p o rtant to rest completely betwee n each repetition. © Holten Institute and To m Arild Torstensen. with permission.
B ox 1 9 . 8
Exercise 8 S e m i -global sta b i l izing a n d m o b i l izing exercises: prone-lying tru n k ext e ns i o n
Fig. 1 9. 1 1
Exerc ise 8 .
• Prone-lying tru nk extension is a progression from exercise 5. By lying further back on the angle bench, less of the upper trunk is lifted against gravity (smaller l ever a rm) (Fig. 1 9. 1 1 ) . Also, range of motion (extensionlflexion of the trunk) is graded based on the patient's available range of comfortable movement. The top part of the angle bench can be angled to acco m modate for this range of motion. Again, the lower back is kept stable du ring the exercise, while working the trun k i n a cran ial--caudal direction. T h e patient fully relaxes between each repetition.T h i s exercise a l s o serve t o mobilize the thoracic spine while partly stabilizing the lumbar spine. © Holten I nstitute and Tom Arild Tor stensen . with permission.
rotation exercises can be performed i n lyi n g . s t a nd i n g
grav i ty w i t h a n additional wei g h t from
and s i Ui n g starti n g positions (Torsten sen, 1 9 9 8 ) . The
( Exercise 1 4 . s e e b e l ow) . A ga i n a l l t h e n e w exercises
deloaded squatting exercises were regraded i n t h a t
were assessed to determi ne the cor rect star t i n g wei ght
the weig h t from t h e l a t i ssimus p u l l ey
was
decreased ,
u ntil fi n a l ly O l av was doi n g sqna tting exercises aga i n s t
a
barbe l l
fo r the patient and t h is weight was l a ter re-a ssessed ( for S tage 4 ) .
Copyrighted Material
1 9 A S O FTWA R E P RO G RA M M E R A N D S P O RTS M A N W I T H LOW B AC K PA I N A N D S C I AT I C A
Box 1 9.9
Exerc i s e 9 S e m i -g l o bal s ta b i l i z i ng a n d m o b i l izing exerc i s e s : prone l y i ng on exte n s i o n stool
Fig. 1 9 . 1 2
Exerc i s e 9 .
• Exerc i s e 9 ( F ig. 1 9 . 1 2) is an e x t e n s i o n of exerc i s e 8 u s i ng a n ew s ta rt i n g p o s i t i o n . Tru n k exte n s i o n is perfo r m ed w h i l e l y i n g p rone on t h e e x te n s i o n s tool w i t h fl exed h i p s a n d knees. T h i s exercise a l s o s e rves to m o b i l ize t h e thoracic s p i n e while p a r tly s t a b i l i z i ng t h e l u m b a r s p i n e . © H o l te n I n stitute a n d To m Ari l d To rste n s e n . w i t h perm i s s i o n .
Box 1 9. 1 0
Exerc i s e 1 0 G l o b a l sta b i l izing exerc i s e : wa l k-s ta n d i ng p u l l down to chest
Fig. 1 9 . 1 3
Exercise 1 0 .
• The a i m of this particu l a r exercise is to sti m u l ate structu res that are stabil izing the back. The patient is i nstructed to flex the knees and h i ps s l ightly. perform i ng the d raw- i n acti o n of the a b d o m i n a l muscles (transversus abd o m i n i s ) wh i l e perfo rm i ng t h e wa l k-sta n d i ng p u l l d o w n t o h i s c h e s t a n d b a c k u p ( Fig. 1 9 . 1 3 ) . To fi n d a comfo r table starting position. the patient has to m ove and position the pelvis a n d l u mbar spine i nto such a position before s ta b i l izi ng. The l oad i ng on the stab i l izing structu res i s i n creased if the speed of the pull down a n d letting u p i s i n c reased. © H olten I n stitute and Tom Arild Torstensen. w i th p e r m i s s i o n .
Copyrighted Material
I '
C L I N I C A L R EASO N I N G I N ACTI O N : C A S E STU D I E S F RO M E X P E RT M A N UAL T H ERAP I STS
Box 1 9. 1 1
F i g. 1 9 . 1 4
Exercise 1 1 S e m i -global m o b i l izing exerc i s e : sitting with back s u p ported fo rwa rd tru n k rotati o n
Exe rc ise 1 1 .
• This exe rcise activates the spinotransversal system, with emphasis on the abdominal and back muscles working in a cran ial-caudal d i rection (Fig. 1 9 . 1 4).The exercise also has a mobil izing effect in a cranial-caudal direction, where the patient rotates the trunk with i n a comfortable range. The angle and p u l l from the pul ley rope determi nes the local ization of resistance. For example, if the rope comes from above, the resistance is biased to the oblique abdominal muscles. To obta i n the 'd rawing-in action ' of the lower abdominal area, the i nstructions are as fol lows : Tighten you r abdominal muscles (or "suck i n you r abdomen and p u l l the naval i n and up") and s i t against the back s u pport putting you r lower back i n a stable starting position. Then turn you r head to the right and rotate the trunk.' For treatment p urposes, the trunk rotation exercises are done consecutively with no rest: first 30 repetitio ns to the right, then 30 repetitions to the left, doing a total of six sets alternating to left and right. © Holten Institute and Tom Arild Torstensen, with permission.
To progress the stabilization o f his l u m bar s p i n e
and later wit h 1 5-2 0 m in ute s warm-up on
an
er go m
fu rther. exercise 4 (Box
1 9 . 4 ) had b e e n i n troduced at Stage 2 w i th a we ig ht of 10 kg; du r ing S t a ge 3 . th e
eter cycle before commencin g the other exerc ises . While this was only a warm-up. it was s u ffi c ie n t for
we ight was progressed to 20 kg and then to 2 5 kg
Olav to break
over 4 week s . The muscles of
the u ppe r extremi ty.
a sweat.
However. everything d i d not go as smoothly as
shoulder and shoulder girdle. the int ers c apu lar muscles
a n ticipated . After 6 weeks of tr e a t ment Ol av was
and other back mu scles extend i ng the spine are
getting a l i ttle bit too motivated a n d i n c reased the
activated by this exercise. Also. the abdo minal muscles
weight on some exerc ises without conferring with
a re activated to counterba lance the activation o f the
me. The increa sed l o ad i n g resu l ted in a s e tb a c k . wi t h
p o s teri or tr u nk muscles.
i nc r e a sed pain i n th e back and in h is left foot. This
In this t h ird ph ase of exercises. Olav continued to
experience m a d e i t clear to Olav the importa nce of
increasing his riding
proper pacing and that in c reas e d loa d in g w i th the
star t with the stationary b ike . time [rom
10 min u tes to 1 5-2 0 minutes. The total
exercises has to be done in
a stepwise ma nner w i thi n
number of exercises was eight and the total tr e a tment
h i s t o l e ra n ce for loading. Thi s aggravation of symp
time was now a pp roxi m a t e l y 1M h o ur s (Table 1 9 . 3 ) .
toms settled after the exerc ises were paced back and
Olav then continued his prog ramme successfu lly for another 8 weeks.
T h e i n trod uction o f global aerobic exercise After approximately 3 to 4 weeks. when Ol av was able
• Stage
4
to sit [or short periods without increasing his symp
The fourth progression of Olav's e x e rc i ses
toms. he started t he lVlET treatment with 5 - 1 0 mi nutes
ried out in
Copyrighted Material
was c a r 1 5 t re a t m ents over 8 weeks ( Ta b l e 1 9 . 4 ) .
1 9 A SO FTWA R E PROG RAM M E R A N D S P O RT S M A N W I T H LOW BACK PAI N A N D S C I AT I C A
Box 1 9. 1 2
Exercise 1 2 G l o bal stabil izing exe rcise: stride side-sta n d i ng two-arm p u l l from one s i d e to the other (short range)
F ig. 1 9 . 1 5
Exercise 1 2.
• Exercise 1 2 is a stabil izing exercise fo r the l u mbar spine. producing a rotational sti m u l u s where both arms and u pper tru n k are req u i red to work against a graded resistance from the p u l l ey apparatus. as if making a golf put ( F ig. 1 9.1 5). Here it is important to keep the l u m ba r s p i n e stable. avoiding any rotation in the lowe r lumbar a rea. applying the 'drawi ng-in action' of the lower abdominal wal l .The i nstructions to the pati ent a re: 'slightly flex you r knees and h i ps , d raw i n yo u r lower abdominal area stabilizing your back. Now. keep you arms straight with t h e e l bows s lightly flexed a n d move them together laterally, first s l owly and then faster. Alternate between the two sides. doing fi rst 3 0 repetitions to the left. then tu rn arou nd and do 3 0 repetitions to the right fo r a total of six sets (three to right and three to left).' © Holten I nstitute and Tom Arild Torstensen. with permission.
Box 1 9 . 1 3
Exerc ise 1 3 Semi-globa l (mobi l iz i ng in a caudal-c ra n i a l di rection) exercise: front s itti ng tru n k rotation
Fig. 1 9 . 1 6
Exercise 1 3 .
• Exercise 1 3 activates the transversospinal system. now with a greater emphasis on the posterior back muscles. the abdo m i nal muscles and the muscles of the shoulder girdle (Fig. 1 9. 1 6) . Th e movement also mobil izes the spine wo rking in a cran ial-caudal di rection. where rotation and side flexion are in opposite d i rections i n extension (i.e. rotation to the right will be accompanied by side flexion to the l eft in extension).Thus. the movement sti m u l ates the normal biomechanics of the spine. enhancing motor control/kinetic control of the complicated muscle synergies of the trunk. Many patients with back pain fi n d it difficult to sit fo r long periods of time and. therefo re, it may be difficult to begin with this sta rting position i n the early phase of the treatment. However, later, when the patient tol erates exe rcising in Sitting, this i s a very i mportant exercise. © Holten I nstitute and Tom Arild Torstensen, with permission.
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C L I N I C A L R EASO N I N G I N ACTI O N : C A S E S T U D I ES F R O M E X P E RT M A N UA L TH E R A P I STS
Table 1 9 .4
E x e rc i s e cha rt fo r s tage 4 of the m e d i c a l exercise the rapy trea tme n t progra m m e
F u l l description Exercise
Format
of exercise
4 repeated
25 kg, 3 sets of 3 0 mai nta i n e d ove r 8 weeks
Box 1 9.4
7 p rogres s e d
3 sets of 3 0 mainta i n e d over 8 weeks
Box 1 9 . 7
1 4 added
7 kg, 3 sets of 30; i n c reased over 8 weeks to 1 6 kg ,
Box 1 9 . 1 4
1 1 p rogressed
8 kg, 3 sets o f 30; i n c reased over 8 wee k s t o 1 0 kg,
3 sets of 3 0 Box 1 9. 1 1
3 sets of 3 0 9 repeated
3 sets o f 2 0 mai n ta i n e d ove r 8 weeks
Box 1 9. 9
1 2 p rogressed
5 kg, 3 sets of 3 0; i n c reas ed over 8 weeks to 6 kg,
Box 1 9 . 1 2
1 0 p rogressed
20 kg, 3 sets o f 3 0 ; i n c reased ove r 8 weeks to 2 5 kg,
3 sets of 3 0 Box 1 9 . 1 0
3 sets of 3 0 1 3 p rogres sed
7 kg, 3 sets of 30; i n c r ea s e d o v e r B w e e k s t o 8 kg,
Box 1 9 . 1 3
3 sets of 3 0 1 5 added
4 kg, 3 sets o f 3 0 ; i nc r e a s e d over 8 w e e k s t o 6 kg,
Box 1 9. 1 5
3 s e ts of 3 0 'Each exerc i s e is d o n e as three sets of 30 repeti tions with a 30 seco n d b reak between sets.
Box 1 9 . 1 4
Exerc i s e 1 4 G l obal sta b i l izing exercise: stri de s ta n d i ng-k nee b e n d i ng t o stoop k n e e sta n d i ng (squatti n g)
Fig. 1 9. 1 7
Exercise 1 4 .
â&#x20AC;˘ T h i s is another stabil izing exercise for the l u m bar s p i n e , where the pati e n t is i n s tructed to keep the l u m bar s p i n e i n a neutral comfortable position wh i l e performing a squatting exercise ( F i g . 1 9 . 1 7). A s i n p r i o r exercises, t h e patient needs to apply the ' d rawi ng-in acti o n ' of the lower a b d o m i n a l wa l l . Together with the stab i l i z i ng structu res of the back, both u pp e r and lower extre mities are i nvolved with this exe rci s e . The exercise is also i m portant, as it is more fu nctional in relation to da i ly activitie s . Š H olten I n stitute and Tom Ari l d To rstensen, with permiss ion.
Copyrighted Material
1 9 A S O FTWA R E P RO G R A M M E R A N D S P O RT S M A N W I T H LOW BACK PA I N A N D S C I AT I C A
Box 1 9. 1 5
F ig. 1 9 . 1 8
E x er c i s e 1 5 G l obal sta b i l i z i ng exercise: l ifti ng exercise
Exercise 15 .
• With th i s exerc i s e . the patient sta n d s s i d eways p u l l i ng the weight using tru n k rotation fro m the feet a n d we ight tra n sference. with m u s c u l a r effort moving from the m i d l i n e towards the periphery ( Fig. 1 9. 1 B). E m p h a s i s h e re is on stabil izatio n , weight tran sference a n d coord i nation/ k i n etic co ntrol. The lower l u mbar s p i n e is aga i n positioned comfortably and th en kept s table d u ring the movement. A set of 3 0 repetitions i s split i nto 1 5 to the right and then
1 5 to the left; th is set is then repeated. © H olten I nstitute a n d Tom Ari l d Torstensen, with p e r m issio n .
In
t h i s fo u r t h
p h a s e o f exerc ises, O l av ma i n t a i n ed
h i s 1 5 -2 0 m i n u t e warm- u p w i t h the s ta t i o n a r y b ike,
sti l l brea k i n g
a
s weal as w i th t h e other p h a ses
of h i s progres s i o n . Two new exerc ises were
� o
added
(exercises 1 4 a nd I S , d escribed in Boxes 1 9 . 1 4 a n d 1 9 . 1 5 ) . T h e total n u mber o f ex er c i s es i n t h i s progr e s sion w a s n i ne a n d t b e t o t a l treatment time was a p proxi m a te ly 1)1 h o u rs .
REASONING DISCUSSION
I n a d d i t i o n to monito ring the patient's pain and
patient i s ex periencing w h e n star t i n g treatme n t and
performance with the exercises themselves, can
o i s sy mptom-free or normal function . Som e t i m e s [ use
yo u discuss any other outcome measures you
a v i s u al a n a l ogue
re-assessed?
the Oswestry Low Back Di s a b il i ty Scale fo r fu nc ti o n .
scale
For O l av 1 u sed t h e 10
an
box scale fo r both p a i n
tion. b e c a u s e my experience is that in
• C l i n i c i an 's an swe r For c l in i c a l usc. I app ly
( VA S ) for measu ring p a i n and
a
a nd fu nc
b u sy outpa
tient cl i n i c work i ng with i n d i v i d u a l pa tients. a s i m p l e ob j ect ive measu re of s u b
jec tive variab l es usi n g a 1 0 box scale for b o t h p a in a n d
1 0 box s c a l e is ca sier to use tha n
a
more abstra ct VA S
and the Oswe s t r y Low Back Pa in Disabil ity Scale. The
d i fferent activi ties of da ily l i v i n g ( fu n c t i o n a l activ i ties)
l atter ou tc o me measures a re more valid doing out
where 10 i s the l eve l o f pain or dys fu ncti o n the
come
re se a r c h comparing d i fferences between l arge
Copyrighted Material
I :
C L I N I C A L R EASO N I N G I N ACT I O N : CASE STU D I ES FROM E X P E RT M A N UAL T H E RA P I STS
pa tient g roups (Torstensen et al . . 1 9 9 8 ) . Olav ' s condi tion did not rea lly ch a n ge much the rtrst 3 -4 weeks,
to the patient hav i n g a fi rm and d e llnite ha nd shake, whether the patie n t looks into the thera
but then pain started to decrease in the leg and the
pist's eyes when s h aki n g hand s . a nd whether the
back and function improved correspo ndingly. His
p a tien t st ates a defmite treatment aim ( e . g . that
strai ght leg raise and slump test signs disappeared
w i thin a certai n time period t hey will be back
and t h e ran ge of motion of his back in aU movement
working a nd doing ordin ary acti v i t i e s as before)
directions improved Significan tly. T h ese variables we re
• w ha t thoughts the p a ti en t has about their sym p
indirectly re-assessed through the progression of his
toms and how quickly they c a n retu r n to work and
m a nagement. Another sign of improvement was the
normal activ i ties o f d a i ly li v i n g with the prese n t
markedly increased load he could tol erate d urin g the
symptoms
exercises, and weight resis tance was increased from
50% to 1 5 0% for most of the exercises . In addition .
• how motivated the patient is enga ging in a n active
exercise- based treatment
improvement was indicated by the fact that he managed
• the patient's pain pattern and
to exercise in star ting positions that earlier were
• the
un bearable because of the pain , such as si tting starts
p a i n be h av i o u r
time the patient h a s been
on sick le avel
u nem p l oyed/o ff wo rk: there is scientific evid ence
and also squa tting exerci ses flexing the trunk forward .
that l en gth of time away from wo rk is a nega t i ve
In the c U nical setting . by co n tra s t with t he research set
predictor for retu rning to work.
ting, it is impor tant to use outcome measures that are patient friendly and understandable for the patient
The t reatme n t is usu a l ly fa i r l y straightforward when
1 9 9 8 ) . Pointing out to the patien t
one can reproduce symptoms and if the symptoms
what they can do now compared with earlier is fo r most
can be rel ated to an orga n ic structu re . Olav had a frrm
patients very motivating. giving them an understand
h a ndshake, was not on sick leave, enj oyed his work
(Torstensen et ill
..
in g that they are actu aUy tTeating themselves and through that action they will get b e t ter An exercise card .
and hoped t h a t . w i t h i n the not too dista n t fu ture, he would be much better a n d wo rki n g norma lly. I also
is used to document obj ectively the progressions of the
j u dge d that he had
treatment. T h e name of t h e exercise. weight resistance.
tom p a tter n i n a recognizable derma tome and d id not
and the number of sets and repetitions is recorded on
a
type r presentation with a symp
present as h a v i n g a ny type of a b n o r m a l p ain behav
the exercise card . Through h i g hli gh tin g the progressions
iour. Other relev a n t i n formation i n d ic a t i n g a positive
the exercise card , I focus on what the pa tie n t can do
outcome i ncluded the fa ct that Olav was norma l ly
on
and what they have achieved, thus adapting cogni
tive-behavioural t herapy for the exercise room.
fa ir ly p hys i c a l l y active and e nj oyed exerc ising. There fore. i n troducing an active treatment from day one consisti ng o f graded exerc ises was l i kely to be well
II
Please c o m m e n t on yo u r p rogn osis for Olav
and the key crit e ria you consider in making t h i s
accepted by Olav. In many ways . I wo uld categorize
O la v as a n ' easy' patient wh ere si ngle d isci pl ine ther apy l i ke MET, would be s u fficient to decrease symp
j u dgment.
,
t o m s and norm alize fu n c t i o n
.
Today, when I get
simi lar p a tients, as wel l as other symptom patterns
• C l i n i cian's an swe r r conside r the fo Ll O W in g rtve e lements are important to
pred i c t i n g outcome:
that are typ ical of ty pe I pa tients , I feel. con ll de n t in o ffering them a positive o u tcome. However. a posi tive o u tcome is dependent on the patie n t being motivated
• how the patient prese n ts h i mself/ herself at the
assessment . i . e . a p os i ti ve outcome i s often related
O utco me
to performi ng the super v i se d graded exercises two to three times a week for
a
period of a t l e ast 2-3 months.
to three times a we ek ) , Olav was symptom free and able to en gage i n a ny da i ly activity. The final test that
A fter a t o t a l of 2 4 weeks o f treatment a n d a total of 47 treatments ( lJi hours exercise therapy two
re c o vered was a tri p with his two sons to Sva lbard 5 months a fter he fi n i s he d the treatment.
he h ad
Copyrighted Material
1 9 A SO FTWA R E PRO G RA M M E R A N D S P O RTS M A N W I T H LOW BAC K PA I N A N D S C I AT I C A
Svalbard i s a n i s l a n d fa r north toward s the No r th
as well as drivin g scooters with pronou nced vibrati o n .
Po l e . During the 1 wee k trip in t h e wil derness they d id
O l a v m a n aged well and never experie nced a ny b ack
a
lot of cross-co u n try ski i n g with heavy b a ck packing .
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44. 1 3- 2 0 .
CHAPTER
20
An elderly woman 't rapped within her own home' by groin pain Patricia Trott and Geoffrey Mait/and
�
S U BJ E C T I V E E XA M I N AT I O N
Moya is an 83-year-old woman who had been recom mended for physiotherapy by her general practitioner (CP). She has intermittent right groin pain that is consistently brought on by standing for 10-15 min utes and walking for 15-2 0 minutes. She also experi ences a sharp catching pain in her groin that is inconsistently associated with standing up [rom sit ting and lifting her right leg to get into
a car or to
put
on her shoe. At night she was unable to lie supine with one pil
G eneral sc reeni n g questions Moya reported good general health. no gastrointestinal or gynaecological complaints or relevant history, no weight loss. and no symptoms of spinal cord or cauda equina irritation/compression. She takes analgesics (two disprin, one or two nights per week) if unable to sleep because of groin pain but has no history of taking steroids or anticoagulants. She has had no radiographs or other tests recently.
low because of the groin pain and found most relief in the half-lying supine position on three pillows. At times she also needed a pillow under her right knee.
P resent h i story
She reported no pain or stiffness first thing in the
Over the last 3 months, Moya experienced a gradual
morning. Her groin pain was worse towards the end
onset of right groin pain for no known reason. There
of the day and some nights she slept poorly because of
was no trauma or change in routine activities at or
the pain. Sometimes this was when she had slipped off
around the time of onset. She had to give up swim
the pillows into a more horizontal position. but at
ming three times per week and working as a volunteer
other times it was not related to position. She could
in a hospice 2 days per week because of her inability to
sleep on her sides. propped on three pillows. but if pain
stand and walk. Because of this. she acknowledged
developed tben she had to return to the half-lying
feeling very frustrated and 'trapped within her own
supine position and this would ease the groin pain
home'. Further questioning revealed that she was
within a few minutes. The number of times she woke
widow who lived alone in a roomy unit. Her two chil
a
per night was variable and was not related to her daily
dren lived vvithin 10 km
activities. Sitting eased both her day and night pain
regularly. She had worked as
within 5 minutes.
aged 70 years and since then had trained as a counsel
Other activities that might implicate the hip joint as
and contacted and visited her a
private secretary until
lor for the dying and for bereaved families and I'riends.
the source of pain (e.g. crossing the right knee over the
She had good insight into her own feelings of being
left in sitting and squatting) were negative. Similarly.
confined to her home and to loss of her hospice work.
there was no pain with activities performed in tTunk
There were no indications of depression. The groin
Oexion. such as cleaning the bath and gardening.
pain was worsening in both intensity (could reach
312 Copyrighted Material
20 AN E L DERLY WOMAN 'TRAP PED WITH I N H E R OWN H O M E' BY G RO I N PA I N
8-9/10) and freq uency with more activi ties bringing on the pa i n . Past h i story
There was no past history of back or leg symptoms. Moya had experienced many years of occipital
head aches , which were h elped by physiotherapy treatment to the cervical spine. In the l ast year, she reported having occ a sional centra l low cervical aching associa ted with sustained flexion . There had been no treatment for this low cer v ical problem and no h i s tory of traum a to the neck.
R E A S O N I N G D I S C U S S I O N A N D C L I N I C AL R E A S O N I N G C O M M E N TA RY
II
• hi p
What were your thoughts regarding this lady and her problem? From your comment regarding activities implicating the hip, you were clearly considering this as a likely source of her symptoms. Could you briefly highlight the clues from her presentation that supported this hypothesis, as well as any that perhaps did not fit?
• C l i n i cian s ' answer It was intUitively felt that th is elderly woman was able to give a n accuraLe description of her symptoms and their behaviour. Moya was qu ite c lear regard ing the cons i stent aggravatin g effect of standing and wa lking and the eaSin g effect of Sitting and supine lying on three pillows. Her difficu lty i n relating the pain's behav iour with other activities seemed more related to their variable effect than to her vagueness. The ea rly hypotheses regardin g the source(s) of right groi n pai n , and the associated evidence, were: •
lumbar spine spi n a l canal stenosis: s u pported by the pain bein g worse with standing and walking and ea sed by Sittin g and half-ly i n g supine: the former narrows the spinal c a n a l. while s itting and h a l f-lying supine Ilexes a n d so widens the canal upper or lower lumbar zygapophyseal join ts, which can refer pain to the g roin: agg ravating and easin g dfects of sta nding and sitting (half lying) , respectively, a re more common ly associ ated with zygapophyseal joi n t problems than with a discogen ic source
jOint ( a nterior structures ): pain felt in wei ght bearing positions of sta n d i n g , walking, movi ng from sitting to sta nding or lifting the leg to get i nto a car: degenerative h i p disease is a com mon sou rce of g roi n pain in patients of thi s age g roup, but the inconsisten t effects of hi p movements did not sup port the hip jOin t as a source of pain • bursae a n d loc a l muscles i n the g roin area: p a i n associated w i t h h i p movements such as walkin g a nd lifti ng the leg to get into a car; however, these movements did not conSi stently ca use pain • neural sources ( ilioingUin a l nerve a n d femoral branch of the genitofemoral nerve): i n ability to lie nat in supine, which c a n apply ten sion to the ilioin gu inal nerve as it pierces the anterior abdom i n al wall, a n d p a i n i n hip extension . which tens ions the femora l branch of the genitofemora l ner ve that pierces the psoa s major • ga stroenterolog ica l and gy n aecological disor ders: c a n refer pain to the groi n (considered u nl ikely). The condition appeared to be: mechani cal (pa i n worse with postures a n d move ments, though the latter showed some incons i st encies) • non-inll ammatory ( no morning sti ffness, no rest i n g symptoms) • non-ir ri table (eased after 5 m i n u tes of s i tti n g or half-ly i n g supine) • peri phera l ly neurogen i c or nociceptive (p a i n mec h a nisms)
•
.
Could you comment on your thoughts regarding the onset and progression of this lady's symptoms?
Copyrighted Material
CLINICAL REASONING IN ACTION: CASE STUDIES FROM EXPERT MANUAL THERAPISTS
•
Clinicians' answer
judgment. one that often leads less-experienced
The insidious onset supports a degenerative process
therapists astray in t heir reasoning and manage
leading
ment. Here the clinicians recognize quite e a rly in
to
lumbar
spinal
canal
stenosis
and/or
osteoarthrosis of the zygapophyseal joints or hip joint.
the patient i n t er vie w that. while local hip joint and
H does not support groin tissues as the source of pain as
surrounding soft tissues are incriminated by the
one would expect
area of sym p t o ms and pattern of aggravation.
a
hi stor y or some incident or trauma.
The central low cervical aching associated with sus taine d neck flexion was not attended to at this stage.
inconsistencies in this pattern are apparent (e.g. degenerative hip joint disease. which is common in
The worsening in inten sity clOd frequency of the
patients of this age gro u p. is more likely to be asso
groin pain. despite a reduction in activities involving
ciated with difficulties cr oss ing the legs and squat
st a nding and walking. suggests that there may be
ting). Attending to features that do 1I0t lit the
other pathology, which needs rurther investigation
typical patt.ern is
by the GP Computed
even experts will proceed with a deductive
a xi a l
tomography (CAT) or
a
characteristic or expert-ise. I-Jere. or
back
best
ward a pp roach to reasoning whereby further infor
demonstrate both the bony and soft tissues or the
mation (subjective and physical) will be sought to
magnetic
resonance
imaging
(MRI)
would
test competi n g hypotheses while still remaining
spine and the spinal canal itselL The feelings of frustration (not depression) seemed
open minded to the possibility that the palien! may
appropriate for this woman. who had led an active life.
have an atypical varia lion of a common disorder.
She kept up her general lltness by swimming three
The clinicians' ac co u n t of this case reveals the
times per week and gainfully employed her mind by
breadth of their reasoning. Their diagnostic rea
doing 2 days of vol u n tar y work. She was now con
s o ning to determine whether manual therapy is
fined to her home and spent most of her time sitting.
appropriate. and if so where should tre atment be directed. is obvious. However. attention is also given to the context of the patient's problem.
• Clinical
reasoning commentary
i.ncluding the elTect the problem is having on her
Intuition. as referred to in the clinicians' first
life her understanding and feelings: what has been called h.�r 'illness or pain experience'. This was dis
response. is
cussed in Chapter 1 as narrative reasoning.
.
a
well-recognized feature of expert
thinking. It typically occurs at what might be ca ll ed
a
subconscious level. based on a general a
combination
of
reaSOD
patient
recognition and concern regarding the worsening
responses and even more subtle cues conveyed in
nature of the pro ble m. Here. consideration to the
impression
from
The other signi fi c ant feature or expert
Lng evident in t.he clinicians' answer is their early
the tone of the patient's answers. demeanor and
boundaries of manLial therapy intervention
behaviour. Reflecting on sllch subtle patterns can
starting to be formulated such that. even though
be helpful to recognize and critique one's own rea
the disorder presents as being mechanical and
are
soning and is critical when attempting to teach
non-irritable and screening questions for red flags
reasoning to others. as is discussed in Section 3.
were negative. thought is already be ing given to
The signillcance of any llnding, whether it is a subjective feature or a physic al sign. is
tEl
a
dimcult
.
the possible n eed for further medical consultation and investigation.
PHYSICAL EXAMINATION
Posture
Functional tests
Maya had very pronated nat feet. worse on the left
Sitting. hip flexion to remove
side: equal leg length: protruding abdomen: rorward
standing produced no pain. In the simulated getting
head posture.
into the left si d e of a car. l ifting and abducting the
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a
shoe. and sitting to
20 AN ELDERLY WOMAN 'T R A P P E D WIT H I N H E R OW N H O M E BY G RO I N PA I N '
right leg gave a sharp catch of groin pain, but was not
(PKB) on the left produced no pain (135 degrees) but
consisten tly repeCltahle.
on t he right reproduced the groin pain and an a n terior thigh pulling
Lumbar spine active movements 'T'here was excellen t
lumbar mobil i ty, Flexion (hands
Oat on noor) showed good spinal and hip movement and there was no pa in with addition of cervicaillexion. Ex tension had
a
good range but the low lumbar spine
stilT: extension reproduced her right groin pain ( u n altered by varying weight through the righ t leg). Both lateraillexions and rotations were full range was slightly
and pain-free, w i th good intersegmenta l movement.
Right hip movements Moya was bi laterally very mobile for her age. Right h ip
and reproduced h e r g rOin Other active movements emd
extension was 25 degrees pain at end of range.
combined movements were full range and pain-free
.
Joint mobility Moya's wrists, elbows, hips and knees all showed gen eral i zed joint h ypermobility
Lumbar spine passive movements
.
Passive inte rse gmental testing revealed some hypo mob il ity but no sympto m reproduction at L2�L3, L3�L4
and L4�L5 with central posteroanterior pas (PA[VM) test
sive accessory intervertebral movement
ing. Unilateral posteroanterior PAIVMs on the left and right from L2 to L4
were
hypomobile and on the right
pro duced local pain on ly. It was considered that the PAIVM tests gave sufficient information to justify excluding passive physiological intervertebral move
Motor control Lumbopelvic and hip moto r control. as assessed by Moya's abil ity to
find neutr al postures and con trol
neutral while l oad ing and diSSOCiating limb move ment. was quite good Similarly her ability to move her .
l umbar spine a n d hips
,
through range and thro ugh
functional tasks revealed good motor control.
ment tests ClL this stage,
Muscles Neural mobility Straight leg raise (right a n d left to
The low abdomina Is and hip adductors m u sc les were
9 0 degrees ) and pas
sive neck l1exion were all pain-free; prone knee bend
pain free on resisted static co n traction an d they had -
[ull extensibility.
REA SONING DISCU S S ION AND CLINICAL REA S ONING COMMENTARY
D
Please discuss your reasoning after the physical
• extreme ra n ge of extension of the right h i p, wh ich reprodu ced her groin pain
examination with respect to the most Significant
• righ t PKB was limited and reproduced her gro i n
physical impairments identified, sources, contributing factors and dominant pain
pain.
mechanisms you hypothesized at this stage.
Hypothesized sources of the impairments were:
• Clinicians' answer Moya's key physical impairme n ts were :
• lumbar spine canal stenosis i nvolving the nerve
• hypomobility of low lumbar extension, which
• degenerative
roots in the c auda equina reproduced her right groin pain
jo ints
• bilateral hypomobi lity of unilateral posteroanterior PANNI tests from L2 to 14 with local pain on the right
• hip •
neu ral tissues
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changes
in
the
zygapophyseaJ
C L I N I C A L R E A S O N I N G IN ACT I O N : C ASE S T U D I ES FRO M E X P ERT M A N UA L TH E RA P I STS
If lumbar spine cana l stenosis was occurrin g in the cauda equina (L1-L2 being possibilities), extension could cause groin pain by n a rrowing the canal of the lumbar spine and further compromisin g the L1-L2 nerve ro ots. The finding that other active movemen ts of the lumbar spine were full and pain-free would also support the presence of canal sten osis . Unilateral posteroanterior PAIVM tests have a more direct effect on the zygapophysea l j oints than central tests. The bila teral hy pomobility at L2 to L4 levels is consistent with degenerative chan ges in the zygapophyseal joints. Reproduc tion of only local pain on the right side was not consis tent with the in tensity or frequency of groin pain experienced by Moya when sta nd ing, waU(ing or lying Dat supine; we wo uld have expected this test to reproduce her groin pain if the zygapophyseal joints were the source. It was hypo thesized that one or two treatmen ts applied to the right-sided joints would cla rify thi s issue, as passive mobilization would be expected to change these j oin ts sufriciently to cause a c hange in the groin pain if the pain was somatically referred from these joints. Reproduction of Moya's g roin pain by the extreme range of hip extensio n could imp lic ate both the hip and neural tissues as the sou rce of impairment, but the inconsistency o f g roin pain with functio n al move ments of the hip and the lack of other hip signs sug ges ts that the hip is a less likely source. There was a similar lack of signs in the muscles and soft tissues in the groin. At this stage of the examination, the neural tissues were con sidered the likely source of this impairment. Neural movement is the likely source of limited right PKB and the reprodu ction of groin pain. PKB indir ectly places tension on the femoral nerve (L2 to L4 spinal nerves/nerve roots), which a n atomically can cause groin pain.
Contributing factors Several factors could be c o ntributory to Moya's problem: • generalized peripheral jOint hypermobility
lumbar-pelvic-hip motor control appeared to be quite good, it still may have contri buted to irritation of spinal and hip structures. Degenerative changes in the zygapophyseal j oints of the lumbar spine may contribute to spinal canal sten osis. Upright activities (involving standi ng or walking) would further n arrow the spina l canal. as would lying Dat in bed. It was considered unlikely that psychosocial issues affected her symptoms signillcantly. Moya was not depressed and was able to present her case in a straightforward manner without outward sign s of emo tion or use of exaggerated lan guage.
Dominant pain mechanisms The mechanisms considered likely were: • peripheral neurogenic (Ll, L2 spinaJ nerves) activ
ity secondary to spinal canal stenosis • Nociceptive stimuli related to right L2-L3, L3-L4
and L4-L5 zygapophyseal j oint pathology • central processing deficit, as indicated by inconsist
ent mechanical respon ses.
II
Were you at all surprised by the lack of any marked physical impairment in this lady's spine and hips given the degree of disability she was experiencing?
• Clinicians' answer More defin ite signs in the lumbar spine had been expected, for example a g reater limitation of exten sion a nd easy reproduction of right groin pain using PAIVM tests. Such sig ns would have been consistent with the painful restriction of standi ng, walking and lying flat supine. The lack of physic a l impairments, iri the face of Moya's disability, in both the soma tic tissues underly ing the area of groin p a i n and in the spinal tissues that can somatically refer to the groin led to the con sideration of more serious patho l ogy within the spin a l canal or a central pain mechanism.
• degenerative changes in the zygapophyseal joints of
the lumbar spine, which con tribute to spinal canal stenosis • psychosocial issues: these were considered unlikely. Ceneralized peripheral j oint hypermobi lity requires effective muscle/motor control and while Moya's
• Clinical reasoning commentary As discussed in Chapter 1, clinical reasoning throu ghout the physical examination should be an extension of the reasoning undertaken during the
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20 AN E L D E RLY WO M A N 'TRA P P E D WITH I N H E R OWN H O M E' BY G RO I N PA I N
subj ective examination or interview. Specific i mpair
re gard ing more serious pathology and elicited a
ments and structures hypot hes iz ed as possibly be i ng
reconsideration of the domi nan t pain
involved are t es t ed
further during the
routine assess
ments of posture: active, passive and re sist ive
ment: and neural and
move
motor control. In this ca se ,
mechanism.
The clinicians' reference to 'expected' fi nd ings reflects their testing of hypotheses. an example of 'reflectioll
in -action' , a recogniz ed attribute of experts (Schon,
inconsistencies noted duri ng the subjective exa mi n a
1983,
examination. While t h i s has not resulted in co mple t e rejection of the structures in i ti al ly postulated as p ossi b ly being involved, it has st ren gthe n ed the previou s COllcerns
tinue throughout the m an a ge me nt , as evident here
tion are
e v i dent
in the p hysic a l
1987). H ypot hesis testing is also seen to con
in the practitioners'
plans
to treat and reassess the
effect of zygapo physeal joint mobilization. The evolv
ing nature of expert reasoning is clearly
evident..
this, the right zygapophy se al joints were more m obil e t es tin g. This was further improved with two app li ca tion s for 45 se co n ds of right unilatera l poste roa n t erior PAIVMs grade IV - and IV +, which p r od u c ed on ly l oca l pa in (Ma i tla n d, 1986). Hip extension and PKB remained una l tered . on PAIVM
Initial treatment was
carried o u t at three visits over
6 days.
• Treatment (day
1)
Passive mobilization ( ri g h t and left uni l ater a l pos teroan teri or PAIVMs ( gr ad es IV and HI) was used to mobilize L2-L5 but not to prod uce any referred groin pain (Maitland, 1986). Fol low i ng this, there was increased low lumb ar movemen t on active extension
provoked was unchanged, as it a l so t ive hip ex tension and PKB.
but the groin pain was
on
ac
• Treatment 3 (day 6) Subjective examination reassessment a good day following the last treat men t: less catch ing groin pain wi t h d a i ly a c ti vit i e s . However, st a nd i n g and wa l kin g were u nchanged, as were her symptoms su bseq u ently. Moya reported
• Treatment 2 (day 3) Subjective examination reassessment There
was no flare in sym p toms after treatment. Her
symptoms and functional activities were un altered.
Physical examination reassessment Lumbar extension. plus combin ation s of extension, lateral l1exion and rotation, no longer caused groin p a in . Interse gm e ntal PAIVM
tests were the same both s ides. Hip extension an d PKB remained un a l t er ed . on
Physical examination reassessment There continued to be no d im c u lt y with sitting to stan din g but sitting h i p flexion to take off her shoe ca us ed a c a t c h of sh a rp groin pain (not rep ea t ab le) . The range of active l u mbar extension was main tained. Lumbar intersegmental tests still revealed hypomob i lity of right L2-L5 zygapophyseal j oin ts , with on ly local pain produced on firm stre tc hi n g . Right hip extension and PKB were unaltered.
Intervention Lumbar rotary m ob iliz ati o n was ap pli ed to both a mixture of gra des III and IV F ollow i ng
sides as
Intervention applications of hi p extension as a strong, sustained (60 seconds) stretch} were app li ed and p rovo k ed a m od era t e degree of g roin pain. Knee l1exion was kept at 90 degrees during th e proc edure. Following this, the range of h ip extension lncreased from 25 t o 35 degrees wi t h on ly a pu ll ing feeling in the g ro i n . PKB increased s lightly (12 5 degrees) but this still r epr odu ced anterior thi gh p ul ling and groin pain; through-range resistance was In prone lying, three (grade IV+
greater than on the Jeft side.
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C L I N I C A L R EASO N I NG I N ACT I O N : CASE STU DIES FRO M E X P E RT M A N U A L TH E R A P I STS
REAS O N I NG D I S CUS S I O N A N D CLI N I CAL REASO NING CO M MEN TARY
D
Were you at all concerned about using strong mobilization in an elderly lady, with respect to
rotary mobilization and
osteoporosis and an unknown, potentially
d irected at improv ing the pain-free range of the ri g h t
serious, spinal pathology that may involve canal
L2-L3. L3-L4 and L4-L5 zygapophyseaJ joints. This
narrowing?
result ed in full-range pain-free lumbar extension.
• Clinicians' answer No. Moya showed no obvious signs of osteoporosis
such as u pper t h or a c i c k y p h osis. and the general screening questions were negative. The rot ar y mobilization was pe rfor me d carefully to lim i t the mov ement to th e lumbar spine and to place
minimal stres s on the thoracic spine: that is, the thor ac i c spine was stabilized in a neutral posi ti on . The uni
lateral posteroanterior mobilization was perfor med to stretch the hy po mobi l e zygapophyseal joints on the right side. While these mobilizations were ftrmly ap p lied. they were not vigorous and the symptomatic respo n se du r i ng appl i cation was con t i nuo u sly monitored. It wa s important to produce s uffi ci en t c han ge in the range and p ai n response of' th e lumbar interverte bral jo i nts to establ ish whether they were a so urce of groin pain and whet her an in cre ase d range of lumbar extens i o n would increase Maya's ab i l ity to sta n d and walk for a l on ger time. The se answers were needed as qui c kl y as poss i ble because of the wo rsen i ng symp toms . Should manual therapy not be useful . then fur ther investigations would be needed.
II
The next treatment. usin g
right-S ide d un i lateral posteroanter i or pressu res, was
Please discuss briefly what prompted you to change your treatment from techniques directed to the lu mbar spine to those directed to the hip, commenting on what you were aiming to achieve.
• Clinicians' answer The aims of treatment were to conftrm the source (s) of the grOi n pain and , if p o ss ible, to treat it mechanically.
first. passive mobilization of the lum bar spine, using cen tral and unilateral (on both sides) pos teroanterior te ch niq ues, was aimed at improving the range of lumbar ex te n si on so th at there would be more extension range available for standing, walking and Oat supine ly i ng . This treatment effected an in crease in the pai n -free range of lumbar extension. At
These resu l t s were considered sulTlcient to d e mo n strate definite changes in t h e grOin p a in and to deter mine whe th er the hip ex tens i on and P[(B signs were related to the lumbar spine. Arter 3 day s . there was no si gn i fica n t cha n ge in the lalter p a ra m eters ; therefore, treatment next involved hip ex tens i on stretches. By s tret chin g the hip in to extension. it was i nte n d ed to confirm that the hip jOint was not the source of groin pain an d to demonstrate any relationship between the hip j oint and the range and pa in res p ons e of the
PKB tes t of neural mobi lity.
• Clinical reasoning commentary WhiJe the body of research-based evidence regard ing validation of musculoskeletal cl inical patterns is lim i ted , the research-based ev i d en ce regarding treat.ment progression is virtually non-existent. Therefore, m an ua l therapists must rely more on empirical experience-based ev iden ce to guide these j ud gme n ts . Treatment procedures must have clear ai ms and reassessment must be tho ro ugh and reg ular for de fi ni tive decisions to be reached. In this case, the clinicians describe the progression of mobilization being made w ith care (i.e. awareness of relevant precautions and selectio n of a proce dure that was judged to be safe) an d with the spe cHk aim of determining the relevance of the spi n al !lndings t o the patient's groin pain, hip si gns and neural signs. All treatment interventions, inc lud ing hands-on manual therapy, have both physical and psychological inf1uences. Nevertheless, when
performed with awareness of the broader psy chosocial presentation, specific proce d ures deliv ered and reassessed for
a
specific purpose (e.g.
increased local segmental mobi lity and decreased
local mechanical sen sitivity) enable cl ini c i ans to gauge the 'mechanical' nature of the problem and the appropriateness of continuing such treatlnent.
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20 AN E L D E R LY WOMAN 'TRA P P E D W I T H I N H E R OWN H O M E ' BY G RO I N PA I N
��sessment ancf furth�er""- treatment • Treatment
, - - .", ; ,
4 (day 9)
I n terve n t ion With the ri g ht hi p i n full e >..1en s i o n , five l arge-am p l i t ude
S u bjective exam i n ation re assess m e n t M o y a re po r ted some i mprovement i n h e r g r o i n pa i n ,
u nc h a n ged ,
b u t overa l l i t was
espec i a l ly w i t h sta n d
i n g a n d wa l k i n g . On fu rther q u es t i o n i n g , she s a i d s h e cou l d not a l te r her g ro i n p a i n b y v a ry i n g her s t a n d in g po st u re
or
1 3 0 de g ree s w i th g r o i n p a i n u n c h a n g ed (1 2 0- 1 3 0 d egrees ) .
va r y i n g h e r s tride l en gth .
s tro n g P K B
( g rade m +)
s tretc hes were applied .
S t r o n g g r o i n p a i n w as p r o d u ce d w i th e a c h s tre tc h a nd afterwa rds there was
a
con st an t a c h e i n t h e
g r o i n . P K B i n crea sed to 1 4 0 d e g rees w i t h mi nima l p a i n (now eq u a l to t he left s i d e ) b u t ti ssu e res i s t a n c e
w a s o n ly m i n i m a l ly c h a n ged . PKB was n o t a l tered by
cer vi ca l Oexion or extens i o n .
P hysical exam i n ation reasse s s m e n t Functio n a l
tes t s revea led s h a r p g r o i n
Moya was a s ked to cease t rea tme n t fo r 2 wee ks
pain
with
standi n g from s i t t i n g a n d a b d u c t i o n o f t he r i g h t h i p , but t h ese were n o t repeat ; l bl c . The ex treme ra n ge of h i p exte n s i o n
caused
g ro i n p a i n . as
did
PKB at
1 2 5 d egrees .
a l l o w the effect of
• Treat m e n t 6
(day
25)
T h is w a s a l so a retrospec t i ve assessmen t . Moya c o n s idered her right g ro i n pain to be
The first i n terve n tion was ri g ht hip exte n s io n w i t h Ilrm s t re tc h i n g ( a s a g rade [V + repe ated wi t h the adclilion of
( M a i t la n d , 1 9 9 1 ) .
and rv - ) abduction
a n d then and then
T h i s restored full-ra n ge
pa i n les s p assive h i p extension but PKB was u nc h a n ged .
un changed
s i n ce
bdore c o nune nc in g trea tmen t. Her a b il i ty to sta n d rem a i ned at 1 0-1 5 mi n u tes before s h e need ed t o si t to rel ieve her p a i n . WaUd ng was t he same ( 1 5-2 0 min u tes) and
s he
s ti l l needed th ree pill ows i n order to
rema i n p a i n - free
during the n igh t . The sharp c a tc hes o f
r ig h t P K B ap p l ied as
gro i n p a i n were a bou t 3 0 % be t ter since treatme n t . bu t
g rade III - large-ampl i tude osc i l la t ory m o b i lization
s he could not specill c ally attrib u te this to treatment of
The a
to
t reatme n t to be assessed .
S u bjective exam i n atio n reassessm e n t
I n terve ntions
a d d u ction
( u n less h e r sy m pto ms wo r s e n ed )
sec o n d i n tervention was
a
without, and then w i t h , 2 0 d e g rees o r h i p exten si o n
(Ma itla n d ,
1 99 1 ) .
neu ral structu res .
On both occa s i o n s , stro n g groin
pain ( ' her pai n ' ) was p rod uced. Re tes ti n g
PKB s h o wed
a sl ig ht i n crease in ra n ge from 12 5 deg ree s to 1 3 5 degrees, with g r oi n pain a n d a n terior t h i g h p u ll i n g reprod uced thro u g h t h e l a s t 1 5 deg rees . Tissue resi s t ance wa s u n c ha nged , bei ng II rst fe lt at 1 10 d e g rees.
• Treatment 5
the lum bar spine. hip j o i nt o r
(day
P hysi cal exa m i n at i o n reasses s m e n t Active l u m b ar sp ine extension w a s fu l l ra n ge a n d pain less and i n tersegmen tal PAIVM tes ti n g revealed similar mo bi l ity on both the left and ri ght si d es . R ight h i p exten sion wa s full range a n d pain-free o n overp ress u re .
R i g h t PKB rem a i ned tight ( 1 1 0-1 2 5 degrees) a n d s ti l l
11)
re produ ced her groin pai n .
S u bjective exam i nat i o n reassessment T here was n o c h a n ge i n symptoms asso ciated w i t h s t a n d in g an d wa l k i n g and t h e symptoms sti ll e a sed
within 5
m i n utes w i th s i tt i n g . Howeve r, catches of
sharp groin pain were defi n i te ly less frequent .
I n terve n t i o n W e expla i ned to Moya t h a t th e ex a m i n a t i o n h a d fou nd i n s u ffi c i e n t a bnor m a l i t ies t o acco u n t for t h e d is ab i l i ty c a used b y her ri ght g ro i n p a i n . Sti ffness o f he r low b a c k j o i n t s a nd r i g h t h i p exte n s i o n had been S i g n i fi c a n t ly im p roved by ma n u a l therapy b u t t h ese
P hysi cal exam i n atio n reassess m e n t
c h a n ges had not res u lted i n i m p rove me n t i n her a b i l
R i g h t hip exte n s i o n wa s fu l l r a n ge w i th a slig h t
i ty t o stan d , wa lk or to lie Oat i n su pi ne . Treatment
p u l l i n t h e g roi n . Right P K B w a s tig h t fro m 1 1 0 to
had not i m proved the tig h tness i n the neura l tissues
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C L I N I C A L R EAS O N I N G I N ACT I O N : CASE STU D I ES F R O M EXP E RT M A N UA L T H E RA P I STS
to the r i g h t le g . It was n ote d t h a t no r a d i o g r ap h s had
neural structures had n o t s i gn i fic a nt ly a l tered her
been take n to date a n d th a t the s e m i g h t p rove help fu l
sy mptoms . F u r ther i nvestigations were s u gge s ted .
in d i agn o s i n g ber prob lem .
A fol l ow- up tele p h one ca l l w as made to the GP a week
It was a g r e e d th a t a l ette r wo uld be sent to her GP
later. The GP ag re ed w i t h the need for fu rther investi
s u gge s t i n g fu rther i nves tigatio n s . This le tter o u tlined
ga t i on s and said that he had referred M oya to an
the lack of ex a m i n a ti o n findings an d t h at trea t me nt
orthopaed ic s u rgeo n . The G P also said he wo u ld
directed to the lumbar spine, rig h t hip a n d r i g h t - si de d
report on the fi n d ing s and future m a n ageme n t .
REASO N I N G D I SC U S S I O N AN D C L I N I CAL REASO N I N G C O M M E N TA RY d e termi n i n g whether a deci s i o n could be m ad e re gard
Determ i n i ng how m u c h c h a nge is s u ffi c i e n t to wa rrant conti n ued treatm e n t must
ing the ces s ati o n of m a nual t hera py a n d referra l ba ck
be o n e of th e most d i ffi c u l t reaso n i ng d e c i s i o n s
to her GP. With Moya, there was no d e fin i t e c h an ge in
m a n u a l therapists must m a ke . Wou l d you
the gro in pain a ss oc i a ted w ith the fu nctional activities
b r i efly d i s c u s s , in the c o n text of M oya 's
de s pite a marked i mprovemen t in l u mb ar and hip
res p o n s e to yo u r va r i o u s treatm ents, the key
s i gns. Of more s i g n i ficance was the l a ck of i mprove
featu res that led you to d i s c onti n u e
men t in the ra n ge of motion a n d thro ugh-range
treat m e n t a n d s e e k fu rth e r i nvestigati o n s a t
re sis ta nce of the PKB test despite s trong s tre tc hi n g .
t h i s stag e ?
c ou ld be hy p ot h e s i zed th a t the tetheri n g of t he neu ral
It
tissue was elsewhere a lo ng t h e ne u rax is .
• C l i n i c i an s ' an swe r From the initial ex am i n a tio n, the wor s e n ing of the
. • C l i n i cal
reaso n i ng c o m m entary
(2 weeks and careru l subj ective a nd physical
r i gh t groin pain ( despite Moya d ecrea s ing activities
S trategic use of a break from trea tme n t
that provoked the pain) was a so urce of concern.
in this case)
Lumb a r s pin a l canal s tenosis was hy pothes ized a n d it
exam i n ati o n and retr os pec t ive reassessment enable d
was c o n si dered that a CAT sca n or MRI scan wo ul d
the clinicians to con firm their earl ier suspicion/
l i ke ly be needed to establi s h the pa tho logy.
hyp o thes i s that the p at ien t ' s symptoms and ac tiv
as
It wa s , therefore, plann ed to establish as qu ickly
ity/pa rtic ipation restrictions were not ca used by
possible whet her manual the r apy co u l d effec t
straightforward impairment in th e lumbar spine o r
a ch ange in the co n s i s tent functional aggravating fac
hip tissues. Importantly, t reatments prov ided during
to rs of sta n ding , walking and ce r tain s leeping postures.
the first five visits, wh ile performed with care, were
Screen i ng q uest i on s prOVid ed no contra indic ations
defini tive, allowing the final decision regard i n g fur
to tre a tmen t ; however, t he l ack of ra dio lo g ic al exam
ther me d ica l consultation and investigation to be
in ation of the lumbar spine, pelvis and h ip was ke p t
reac h ed as q u ickly
in min d . T herefore, so long as he r symptoms were
this n ature are cri tical to determine the a ppropriate
as
p oss i ble.
Trial treatme nts of
not worsened by treatmen t . it was pla n ned to use tech
ness of c o ntinued manual t herapy and to be able to
n iques to effect su flIcien t ch a nge in the lumbar si gn s to
inform t.he referring doctor so that further
be a b le to expect a definite ch an ge in standing, w a lki n g
i nterventions can proceed with confidence a nd the
and s lee p i n g pos tures, and to de mo nstra te a ny rela
knowledge
tio nship with the h ip extension and PKB test I1n d i ng s .
the symptoms has been eli m inated . This course of
It was t h e extent of chan ge in the l u mbar s i g ns ( i n tersegmental mo b U ity/ p a i n response ) , hip sig ns
med ical
that a simpler musculoskeletal sou rce of
act i on may contrast with that u ndertaken by
a
less
expert clinici a n , who is more likely t o pers i st with
and ne ura l sig n s , rather than the rate or ex ten t o f
manual treatment on
c h an ge i n the fu nctio n al activities listed above, which
s i gn s , with undesirable consequences or delayed
g u ided the t ime spent i n trea ting the various areas and
appropri a t e manageme n t .
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the basis or improved lumbar
20 AN E L D E R LY W O M A N ' T R A P P E D W I T H I N H E R OW N H O M E' BY G RO I N PAI N
i njection that afforded no relief of symptoms. He
Assess ment by m e d i cal practitioner
advised that noth i n g further sho u ld be done; however, Moya wanted the matter exp lored fur ther.
The GP teleph o ned to repor t that he had sent Moya to two orthop aedic surgeons. The first had p la in radio graphs taken o f her l u mbar spine, pelvis and hi p s
and a CAT scan of her lumbar spine. The radiograph s showed advanced arthritic cha nges bilaterally of her mid/low lumbar zygapophysea l j o in ts and that both h ips were reported as having minor degenera tive chan ges. The CAT scan showed only minor n a r rowing of the spina l canal . The surgeon gave her a n epidural
[Iij D
The second orthopaedic s urgeon injected Moya's right L2-L 3 , L3-L4 and L4-L 5 zygapophyseal jOints with steroids, following which she had a red uction in the ri ght groin pain [or 3 d a ys only; repeat injections 6 weeks l ater w er e of no benefit. I t was a g reed t h a t no further treatment be given at
th i s stage and that both the GP and Moya s h o u l d mon i tor h e r symptoms.
R EAS O N I N G D I S C U S S I O N The short-term relief from intra-articular injec
H ow d i d you i n terpret her lack of any lasting ch ange from the s u rgeo ns' i njectio n s ?
tions into the L2-L 3 , L3-L4 and L4-L5 zygapophyseal j oints may have resulted from the e ffect of the local
• C l i n i cians' answe r
an aesthetic. which is incorporated with the steroid , or
If indeed , there was only minor narrowing of the l um bar spinal canal. then an epidural injection might not be
expected to relieve her symptoms. The clinical pattern was highly suggestive of spinal canal stenosis, which is
i t may have been a short-term pl acebo effect. The lack
o f a lasting improvement also may ret1ect that the source of her pain was not w i thin the lumbar spi nal canal or zygapophyseal j O i n ts.
the likely reason why an epid ural injection was given.
Re- presentation fo r treatment
w i th her groin pai n s . She had no other leg symptoms and bl adder and bowel fu nctions were normal.
Moya referred herself for more treatme n t 7 months later. She corroborated the details in her GP's report
F u n ction ally. her groin pains i nterfered
wi
th her
sleep and her GP had prescribed a n a l gesics a nd a
of the investigations and outcomes of treatment by
s leeping tablet . She slept in the sitti n g posi tion with
the two orthopaed ic s urgeo ns.
three pillows; supine ly i n g was more comfor table
Moya reported that for the last 5 months s he h a d
than on her sides. To get out o f bed on the left side to
ex perienced more consta n t right gro i n p a i n with the same pattern as before. namely a ma rked i n crease
go to the toi let was extremely painfu l i n both grOins. left more than right. She w a s unable to stand erect [or
with stand i n g more than 10 minutes or walki n g for 1 5 minutes . S itti ng still eased the p ai n within a fe w minutes. Then l a s t week . suddenly for no apparent reason . the pain became bilatera l and spread to the anteromedi a l aspects o f both thighs and to the s h i n on the left w h e n severe. When questioned, she also ex perienced deep cen tra l ach i ng i n the low cervical. low thoracic a n d low back areas. which she described as minor compared
more than 5-1 0 m i n u tes because of b i l ateral groin p a i n and a d u ll low back ache. S i tting ea sed the p a i n i n less tha n 5 minutes and she spent most of t h e d a y s itting i n a n armcha ir. Standing w a s worse fir s t thing i n the morning (but "vith n o stiffness) a n d in the
evenings, and she tended to b e bent forward for the fi rst few steps. The groin p a i n seemed u n re l a ted to her hip movements.
Copyrighted Material
C L I N I C A L REAS O N I N G I N ACT I O N : C A S E STU D I ES F RO M EX P E RT M A N UAL T H E R A P I STS
REASO N I N G D I S C U S S I O N A N D C L I N I CAL REASO N I N G C O M M E N TA RY
D
What was yo u r i nterpretati o n of the wo rs e n i ng
• c o n c o m i tant low cervica l . low t h oracic a n d low
natu re of h e r sym pto m s a n d d i sabi l i ty ?
l u m b a r a c h i n g . w h i c h m ay s u ggest p a t ho l ogy a ffec t i n g the structu res a n d con te n ts of t h e spi n a l
• C l i n i cians'
c a n a l a n y w h ere from t h e cer v i c a l s p i n e t o t h e l u m
an swer
b a r s p i n e re gio n s
T h e s u d d e n worse n i ng of sym ptoms was most c o n cer n i n g rega rd i ng t h e l i kely pathol ogy. It was decided to perform a thorough p hysical exam i n ation. bei ng ca refu l not Lo provoke h e r g ro i n / a n te r i o r t h i g h p a i n a n d to a s k Moya t o b ri n g h e r rad i o g r a p h s a n d reports
.
T he p a i n m e c h a n is m was s tron gly n e u roge n i c w i th
a
m i x t u re of central a n d peri ph er,i I sympto m s . t he fo r mer acco u n t i n g fo r a less c lear p i c t u re
of c a u s e a n cl
respo n s e to mec h a n ic a l s t i m u l i .
a t t h e n ext v i s i t . T h e prov ision of m a nual t h erapy trea tme n t would be gove r n e d by these D nd i n gs and
a
d i s c u ssion w i th her G P M oya 's responses to the s u bj e c t i ve ex a m i n a t i o n su gges ted
a
• C l i n ical
reaso n i ng c o m m entary
With recogn ition of
a
and
worse n i n g problem
pote n t i a l ly si g n i llca n t if not s i n ister p a t h o l og y t h e
s p i n a l c a n a l source as i n d i c a ted by :
.
decision w a s m a d e t o make a fu r t h er t h orough • t h e c h a n ge to
a
b i l a t e r a l pro b l e m . now worse o n
t he opposite side • the d i s tribution of pa i n , which was consistent w i th a
physica l exam i n a tion . to correlate with t he now
subjective pat tern of presen t a t i on . The of t h e disorder has been respected and will gu ide the care p l a n n ed for t h e
con sisten t
Ll -JA neu roge n i c s o u rce ( b u t w i t h no blad
der/ bowe l c h a n ges at this stage)
potential serio usness
p hy s i c a l t e s L i n g . No assumptions have b e e n made
• u n i later a l movements o f the left hip causing b i l a t eral g r o i n pa i n
that the physical fi n d i n gs w i l l necessarily be the same a fter 7 months; their cmefu l rea ssessme n t will
• tbe u n c h a ng i n g beh aviour of sympto m s , that i s ,
c o n s istent with c h a n ges i n a n teropos terior d i a
provide a fu ller pict ure of a ny physica l impa irments that may be pre se n t i n c l u d i n g any re lationship to
m e t e r o f the spi n al c a n a l
the original and new sympt oms. I n t h i s way,
• t h e s u d d e n o n s e t o f symptoms for no a p parent r e a
.
s o n . whic h does n o t s u p p o r t the j o i n t s / m u scles o f
fu rther
the l e g s a s t h e cause
means) and med ica l i nvestiga t ion
tE
more
i n formed decisions regard i n g t he appropriat eness of reh abilitation ( v ia m a n u a l t herapy can
or
ot her
be made.
P H YS I C A L E X A M I N AT I O N
S t a n d ing fro m sitti n g cau sed b i l a tera l g ro i n pa i n ,
hy pomob i l i ty or p a i n . but rather general i z ed hypomo
w h i c h was u n a l tered by t h e deg ree of weight-bea r i n g
bil ity from L2 to L 5 .
throu g b e a c h leg o r by a l ter i ng h i p rotat i o n . Left an d right h i p m ove m e n ts
L u m bar s p i n e active m ove m ents
Left a nd r i g h t h i p movemen ts were fu l l ra nge a n d
F lex io n a n d flex i o n p l u s cerv i c a l flex ion were fu l l
p a i n-free.
r a n ge and did n o t alter t h e g r o i n p a i n s . Exte n s i o n a n d b o t h l a tera l flex ions were ful l ra nge a nd c a u sed a l o w back ac he cen t r a l ly. There was no g r o in or anterior
thig h pain with passive overpressure i n tersegmental
PAIVM
testi ng
a d ded . Pass ive
s howed
no
foc a l
N e u ro l ogical exam i nati o n N o a b n or m a l i ty w a s d e tected i n n e u rCl I c o n d uction of the lower limbs. There was n o ankle clonus.
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20 AN E L D E R LY WO M A N ' T RA P P E D W I TH I N H E R OWN H O M E' BY G RO I N PA I N
hypertonicity o r hyperreflex i a , and plantar res ponses were norma l .
Neural mobility Left a n d right straight leg ra ises were 8 0 deg rees w i t h n o pa i n provoked , i n c l u d i n g w i t h the add i ti o n of pas sive neck flex ion , a n kle pla n ta r fl e x i onl i nvers i o n o r a n k l e d o r s i fl e x i o n , PK B o n t h e left w a s 1 0 0 d e g rees and prod u ced a p u l l in g feel i ng o n the a n terior t h i g h with g r o i n pa i n , R i g h t P K R was 1 20 d e g re e s w i t h a n a n t erior thi g h p u l l i n g sensa t i o n a nd abnormal res i s t a n ce to movement be twee n 1 0 0 a nd 1 2 0 d e g rees .
Slump testing
described bilateral nu mbness in her h a nds and d i fll culty with line fi n ger movements such as doing u p b u t tons and ty ing shoelaces . These symptoms had come on for no k no w n reason in the last 3 months; s he fel t these symptoms were slowly worsening b u t h a d n o t consu l ted her GP Maya reported that s he did not have her radiographs and that they were held at the GP's clinic.
Physical examination reassessment It was dec ided to u n dertake a neu rological exa m i n a t i o n of t h e u p p e r and lower extremities as a prio rity.
N e u ro l og i c a l exam i nati o n of t h e u p p e r
Slump testi ng ca used severe a nterior n e c k pain INi th
cervic a l flex i on to tru n k flexion, so cer vic a l flex ion was released short of pain provocatio n , Left k nee extension l a cked 1 0 degrees but produced no p a i n , a n d added left a nkle dorsiflex ion was ful l range and pa i n less. R i g ht leg testi ng was n ormal. t h e add ition of
Effect of examination Afterwards Moya repo rted that she fel t d izzy and u nwell . Further exa m inatio n , especial ly of the cervical spine, was considered contraind icated in the ligh t or the unknown and worsening pathology. After 30 min u tes of res tin g in the half- lying supine position, her dizziness and unwell fee ling h ad settled and she went home. She was asked to bring her radiographs at the next trea tment.
• Further examination Moya retu rned 2 d ay s later for a fur ther examination,
Subjective examination reassessment Moya reported feelin g disorientated a nd had tachycar d i a [or the rest of the d ay fo l lOWi n g the previous exam ination; the next d ay she felt u nwel l and lethargic. On detail ed q uestioning, she a dm i tted having h ad this feeling several times in t he last 2 mo n th s incl uding a fee l i n g of poor balance. She h a d not ex per i e nc e d t he an terior neck pain before or since the last a ppointment. Because of her p as t experience of a feeling of poor bal ance, deta iled q uestioning of the presence a n d behav iour of upper quarter symptoms was conducted . S he ,
extrem ities
There was loss o f s e n s a t i o n to l i g h t touch over the whole o f both h a nds, but sensation to p i n pri c k was variable: d i m inished i n so me a reas and hypersensitive in other parts of the ha n d s , Upper limb reflexes were ex aggerated, Asterognosis (loss of ability to recogn ize s hapes when held) was p resent in both hands, There was no i ncreased to n u s , but there was wea kness of a l l muscles in both her a r m s ,
N e u ro l ogic a l exa m i n at i o n of the l ower extre m i t i e s N o a b norma l ity was d etected .
Intervention At this poi n t , it was obvious that Moya s h o u ld receive u r ge n t med ical investiga tion of her neuro logica l sta tus. No fu r ther exa m i nation was u ndertake n ; this i n c l uded reassessm e n t of t he l umbar and neura l mobi l i ty signs and exami nation of the cervical s p i n e as t h e fi n d i n g s were u n l ikely to shed l i g h t o n the l ike l y pathology or a l te r the need for u rgent med ical investi gation and m a n agement. A n expl a n a tion was given to Moya that she had symptoms a nd signs of ne r ve invo lve ment' in her arms that could be originating from her cervical spine, and that there could b e a connection between t h is a n d h e r groin/thigh p a ins , Further medic a l investigations were needed and an appo i n tmen t was made for her to see her G P that day. Moya took a letter for the GP that o u t l ined t h e ex a mi n ation fi n d i n g s .
Copyrighted Material
'
C L I N I C AL R EAS O N I N G I N ACT I O N : C A S E ST U D I ES F RO M E X P ERT M A N UAL T H E RA P I STS
R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R E A S O N I NG C O M M E N TA RY
D
• Cl inicians' answer
W hat was you r i n terpretati on of the severe reaction to the s lump test?
The neu r o l og ica l ex a m i n a ti o n co n llr m e d
• Clin icians' answer At the time of pe r fo rmi n g the slump test . the prod uctio n of severe anterior neck pain co uld not be dellrritively int er pre ted . However, because of the worsenin g symp toms a n d signs in the presence of unlmm"lIl patbology. it was n ot considered prudent to repe at the tes t but rather to lessen the cervic a l flexion so that the effect of caudal mo b i li ty tests on the neural tissu es could be ex p l ored At
the
seco n d
apPo i n tment.
the
matter
.
was
explor ed fu r ther. The presence of what s o u nd ed like cervical spinal cord sy mpto ms felt b il aterally in the upper
s tre ng the n ed
limbs
t he
like l y
r e l a ti o n sh i p
between cervical s p i n a l cord pathol ogy a nd p ru n fel t on the a d d i t i o n o f cervical l1exion to t h e s l u mp tes t.
D
a b il a tera l
p a t tern of cervical sp i n a l cord compressive s i g n s that extended fro m C4 to T l . This su ggested a lesion s o me
.
• Cl inical reasoning commentary As
we
h ave seen in other c a ses in this boo k . a n
impor t a n t decision
c l inicians face is whether fur
t he r m a n u a l therapy man ageme n t is warra n t ed . Here the n eurologic a l fi ndings comb i n ed with the wor se n i n g
n a t u re of the s y m p t o ms d i c t ated t h e
decision La in itiate fur t h e r med i c a l cons u ltation and not recommence any physica l rehab i l i tation
at t h is stage . Red flags (Roberts. 2 ( 00) and t h e i r a n essen t i a l p a r t of
W hat was yo ur i n te rpreta tion of these most
assoc iated i mplicatio n s
recent neu rological findings ?
m a n u a l t herapist 's kn owl ed ge base.
ar e
a
O utco m e Maya was referred t o a n eu ro l ogist w h o d ia g n os ed C3-C4 myel o pathy and su b s eq uen t MRl c o nfirmed a h u ge osteophyte protru d i n g fr o m the posterior aspect o f C4 a n d i nde n t in g the s pi n a l cord by more than 50% (Fig. 2 0 . 1 ) . Degenerative ch an g e s were presen t in the cord a t this leve l . Simil ar, but l e s s m arked cha nges -
were noted at C5-C 6 . A neu ros urg e on removed t he
ost e op hy te s and fused b o t h areas . S i x mo n t h s after the cer v ical fusion, the ne u r o lo
g ist refer red Maya for assistance w i th poor ba la nce on w a l ki n g He noted t h a t her ne u r o l ogi c a l defici t was .
stable, b u t t h a t w it h o u t the su rgery she wo u l d h ave become a quadriplegic.
Of
speci a l
i n terest
h a d exper i en c ed
was
the
fact
that
M aya
no fu rther grain or a n t ero me di a l
thigh pain immed iate ly following the s u rgery. On exami n a t i o n
,
PKB on both si des was 1 4 0 deg rees
with only a n teri or t h i g h s tretc hi n g fe lt a n d the throu gh r an g e re si sta n c e -
l o n ger presen t .
p rev i o u s ly
fe lt
was
no
where in the v ic in i ty of C4 t h a t i nvol ved both sensory and motor tr ac t s to the u ppe r l imbs but spa red those to the lowe r l i m b s
Fig. 20.1 Magnetic resonance i mage demonstrating a large osteophyte protruding fro m the poste rior aspect of C4 i n to the spinal canal and i n denti ng the spinal cord.
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20 AN E L D E R LY WO M A N ' T R A P P E D W I T H I N H E R OWN H O M E ' BY G RO I N PA I N
Moya remains free o f groin and thigh symptoms . S he presents every f) months or so [or treatmen t for
her occipi tofrontal headaches, which are mostly occipitoatlantal joint in origi n .
R EASO N I N G DI S C U SS I O N AND CLI N I CA L REAS O N I N G C O M M E N TA RY
II
• C l i n i c i a n s ' answer
With the advantage of h indsight, do you co n sider there were any features of this lady's presentation when she initia l l y presented to you that you may have over- or underweigh ted?
• C l i n i c ians' answe r Yes . with h i ndsight. by t h e fourth visit more weight s h o u l d have been pl aced on the role o[ a central pain mechanism for her groin pa i n . The focus was more on the consistent eITects of sta nd ing, waUting and h a l f lying su pine, and to a lcsser extent on the many times in the day that she inconsistently felt sharp groin pain with activities. The significance of the [act that the range and through-range resistance of PKB changed very little, even with strong stretching, was also u nder valued. It shou ld have nagged the need to consider tethering of neural tissues a t a more proximal site. A lso, reflection on the MRI scan resu l ts and fInd i n g a t surgery provided a likely explanation for the severe pain experienced with the slump test . During flexion, the contents o f the s p i n a l canal are drawn more tightly against the ver tebra l column and , there fore, against the protruding large osteophyte at C 3 -C4 (G rieve, 1 9 8 1 ) .
EJ
Degenerative c h a n ges per se need not ca use local or
referred symptoms. In contrast with the lumbar s p i ne, the cerv ical spinal canal is rel ative ly large and can , therefore , accommodate osteophytes from the zygapophyseal joints or vertebral bod ies (Grieve, 1 9 8 1 ) . In Moya 's case, the posterior osteophytes were midline a n d , therefore, did not impinge upon or irri tate more l aterally placed nerve roots . Imp r oved range o[ the lumbar zyga pophyseal j o ints and the hip j oi nt was an expected ou tcome of end-ran ge passive m o b i l ization: however. there �w as no consistent improvement in groin pain associated with d a i ly ac ti v i ties The lack o f consis te n t res ponse was most Itkely a consequence of a d om i n a n t central pain mechanism related to cervical myelopathy. .
• C l i n i cal
reason i ng c o m m e n tary
Refle cti o n , as ge n er o u sly shared here, is the means by which manual therapists learn from their own experiences. It is easy to assume that the expert, bein g an
'expert ' , does not make 'crrors' and
resolves all p atie n ts pro blems '
.
As all the experts
contributing cases to this book wUl acknowledge,
Could you discuss your thoughts on why this patient had relevant cervical pathology
th i s is far fro m the truth . Experts, like e ve r yo n e , do make err o rs The difference perh aps is their ability to learn from their e rro rs which we believe is closely linked to their metacognitive skills , be they deliberate or intuitive. It is through this p roce ss of continual reflection and critique that experts mod ify their future in terpretations, ac quire new p atter n s and develop variations of m a n age me nt strategies . .
but no upper q uarter symptoms until the last
,
3 to 4 months? Also, why do you thi n k some ea rly treatments produced changes in her groin symptoms and signs if the sou rce was in fact cervical pathology?
• Refe re n ces Grieve . G . P. ( 1 9 8 1 ) . Common Ver tebra l J O i n t P rob l e m s Ed i n b u rgh: Churc h i l l .
Livingsto n e .
Maitl a n d . G .D. ( 1 9 8 6 ) . Ver te bral Manipu l ation . 5 t h ed n . Oxford : Bu tterwor ths. Maitl a n d . G . D. ( 1 9 9 1 ) . Peripheral
M a n i pu l a ti on 3 rd e dn . Oxford: .
B utterworths. Roberts. L . ( 2 0 00). Plagging the d anger
back p a i n . I n Topi cal Pain 2. Biopsyc hosoc ial Assessment. Relatio n s hips a n d P a i n (L. Gifford . e d . ) pp. 69-8 3 . Palmouth. signs o f l ow
Issues of
Copyrighted Material
MA: CNS Press. D. ( 1 9 8 3 ) . The ReDective Practitioner: How Profession a l s Think
Schon,
in ActioD . New York: Basic Books.
S c h o n . D. ( 1 9 8 7 ) . Edu ca tin g the Ref1ective Practi tioner. San Prancisco, C A : Jossey-Ba s s .
C H APT E R
C h ro n i c pe ripartu m
21
pelvi c pai n
John van der M eij, Andry Vleeming and Jan M ens
�
S U BJ E C T I V E E XA M I N AT I O N
M a ree. aged 3 4 years . was referred to the ou tpatien t
Her compl a i n ts were p rovoked by tu r n i n g in bed .
clinic at the Spine a n d Joint Centre ( SIC) in Rotterda m .
sitting ( p a r t i c u l a rly in a n exed lu mbar spine positio n ) .
t h e Netherl a nd s . She comp l a i ned o f persisten t. deep
mov i n g fro m s i tt i n g to s t a n d i n g . s t a n d i n g fo r longer
pelvic pain described as stabbing. pres s i n g a n d b u r n
t h a n 4 m i n u te s . and wa l king or lying supine for more
i n g . T h e p a i n w a s worse over the left p o s terior s u perior
t h an 1 0 m i n u tes. Chan ging position gave parti a l
i l iac spine (PSIS ) and gluteal region . with some pain
relief fo r a s h o r t t i m e . Ma ree sle p t . o n average. o n l y
left of the pubic symphysis and coccy x . There was p a i n
2 h o u rs p e r n i gh t beca use o f the p a i n . There w a s n o
referred i n to the ven tra l and dorsal aspects of the left
p a r t i c u l a r t i m e o f t h e d a y when tbe compl a i n ts were
leg as fa r as the knee j o i nt. The pai n was accompanied
wor s e . However. in th e week prior to mens truati.on
by a tingl i ng sensation thro u g h o u t the entire left leg
her p a i n i ncrea sed and her stamina decrea sed . Maree
(Fig.
2 1 .1).
took sleep med ication a n d occas i o n a l ly parace tamol to re lieve the pain. There were n o prob l ems with her ge n e r a l h e a l t h . i n c l u ding no c urrent or p a s t history of gas troen tero logical or gy n aecolog i c a l conditions. In a d d i t i o n . there was no current or p a s t history of fra ctu res . neop l a s m s . in flamma tory d i sease. or prev i o u s s u r gery or problems o f the l u mbar spine or pelv i s . Maree's compl a i n ts bega n i n the fi fth mon th of her fi rs t pregna ncy. slowly i n creased u n t i l s he gave birth 6 months pri or to the i n terview. and conti n u ed to per s i s t . with a n exacer b a t i o n whi lst attend i n g a s y m po s i u m 2 mon ths e a r l ier that involved prol o n ged sitting. She had been seen by numerous i n d ivid u al heal th care practi tion e r s . received
c o n ll ic t i n g
From
these
su ggestions
prac ti tioners. and
s he
i n formation
concer n i n g tre atme n t a n d ex p l a n a ti o ns fo r her sy mp Fig. 2 1 . 1
M a p of the patien t's sym pto m s . Th e da rke r
toms . A lthough her respon se to pass ive tre a tment
shaded a reas represent pain a n d t h e l ighter shaded areas
was variable. n o s i n gle treatment was conSistently
rep resent the tingl i ng sensati o n .
effective.
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2 1 C H RO N I C P E R I PA RT U M P E LV I C PA I N
R E A SON I NG D I S C U S S I ON A N D C L I N I C A L R E A S O N I N G COMM E NTARY
II
What were your first i m pressions of Maree's presentation, with respect to both biomedical and psychosocial considerations?
• C l i n i c i ans'
h ave been treated elsewh ere predom i n a n t ly with
answer
The first impress i o n was th at Ma ree
structu re-d i rected t herapies t h a t h ave fa i led . such a s
w a s desperate
and th a t s h e h a d used a ll he r energy to escape fro m h e r s i tu a ti o n . The m o r e she fo u g h t . the worse s h e w a s trapped i n
a v ic
i o u s cyc le of p hy sic a l dys fu nction, p a in ,
fatigue, and d epressi o n . The re l ati o n s h i p of t h e o n s e t o f h e r p a i n w i t h h e r
Pain in t h e and pelvic region is a com mon compli
pre g n a ncy w a s a l s o co nsidered i m por ta n t . l u m b a r sp i n e
a nd posterior p e l v ic pain ( P PP) s ta r t i ng duri n g p reg n a n cy o r wit h i n 6 weeks a fter delivery. and with a duration of more t h a n 6 m o n t h s . T h e patients we see
c a t i o n of preg n a n cy a n d delivery, w i th the repor ted
9-month preva l ence rate d u r i n g pregna ncy ranging from 4 8 t o S 6 °/r) ( Be rg et a I . , 1 9 8 8 ; Fast et aI . , 1 9 8 7 ; O stga a rd et aI . , 1 9 9 1 ) . In s t u d i es of yo u n g a n d mi d d l e-age d women with chronic l ow back pain, 1 0-2 8 % state t h a t t h e i r fi rs t epi sode of b ack pain occur red d ur i n g pre g n a ncy ( Sve n s s o n e t al . . 1 9 9 0 ) .
in the c a s e o f Maree. W e overcome the
issue o f con
O i cti n g messages by employing a mu l ti fa c tor i a l and i n te g r a t e d treatme n t a p pro a c h .
and by a t te m pti n g to
m ak e sense of s eemi n gly non-re l ated com p l a i nts. Our a p p r o a c h c a n b e d e s c r i b e d a s fo l l ows ( V l e e m i n g .
1998). In me d ic i n e t here i s genera l ly a n evo l u tionary pattern that sta r ts w i t h the s t u dy of symptoms and s i g n s . From that level. it becomes fe asible to a n alyse the rel ations
between symptoms and to
describe a syndrome. With a d v ancin g knowl e d ge.
a more causal pathophysiological ex p l a n at i o n be fou n d t h at d escribes t h e und e r lyi ng
can
mechanis m . The
physical path predomi n antly tal<e n to
study the locomotor system i s ma i n ly based on
II
red uces systems into such as bones. muscles, nerves . etc. are studied in iso la tion , which does not allow sufficient in s i gh t in to the complexities of the function of the human locomotor system. The topog raphic anatomy that
How did the conflicting messages that the
simple parts. StTuctures
patient had received from the various individual health-care practition e rs infl u ence her behaviour, particu l ar l y with regard to a potentia l col laborative approach to her p rob lems?
practical conseque nce for patie n ts often is th at
• C l i n i c i ans' answer
k i nemati c systems are a n alysed
S he wa s g re a t l y clist urbed by the lack o f c l a rity from the v a r i o u s he a l t h -c are s e r v ice s , i n cl u d i ng a lack or a d istinct d i ag n o si s . In genera l , the c o n fl icting messages te n de d to worsen the p rognos is a n d co m p l i c a te the situ a t i o n . particu larly as Maree was g rea tly d i stressed . For i nsttlnce. advice to rest in bed gave her some tempo rary relief from p a i n but probably i n cre as ed her muscle weakness. In contrast, performing prescribed
exercises so meti mes res ulted in more pain in the short term but iU<e ly i m p roved her muscle stre n g t h .
by alternating between b e d re s t a n d exercise, resul t may we ll h ave been both increased mus cle wealmess and increased pain . in com b i n ation wi th p hysic al and ps ycho l o g ic a l ex haustion. A c on s i ste n t . col l aborative a p p ro a c h was con
However. t he end
sidered more desir a b l e . A t the SIC we spec i a l ize i n the
multidisc iplinary ma nagement of chronic low b a c k
and d i ag n o sed
at tissue leve l . using increa s i n gly sophisticated tec hnol ogy to search for q u an t i fi a b l e p hys ic a l
m ainly prod u c in g a description of Frequently. this search does not ai m to reach a s peciftc cli a gnosis b u t to excl ude se r io u s c a uses of l u m b o pe lv ic pain . If t h e 'impaired' structure can be identified , predOminantly s ingle mod ali ty tTeatment is ind ic a ted to so lve the prob lem, without sufficient consideration of the con impairments,
symp tom s .
sequences for the kinematic system as a who le.
n structural identifi cation fails . p atients are easily classifted as sufferi ng from non-speciftc low back pain or a psychosomatic problem. quo tation emph asizes t h at s i n g l e ap p r o ac hes based on l i mited or restricted theoretica l c o n s tr uc t s do not provide a n ideal means of m a n a g e me n t for p atients with chronic lumbopelvic The
above
m od a l i ty
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C L I N I C A L R EASO N I N G I N ACT I O N : CASE STU D I ES FROM E X P E RT M A N UA L T H E RAP I ST S
pain. Pelvic pain comprises p hysiol ogic a l , psych ologi cal and b e h avio u r a l dimensions , which inter-relate with one another. Patients with pelvic p a i n , such as Maree, req u ire an i n tegrated multifactori a l a pproach i n wh ich one o [ the main goals is to restore the patient's control over h i s o r h e r own b ody a n d life. Both practitioners and patients may need to partici pate i n a paradigm shift from a medical model to a sel f-healing model in which a ' h ands-orf ' approach i nvol ving self-man agement a nd education is essen tial. rather than the practitioner actually ' solving' the patient's problem (McIndoe, 1 9 9 5 ) . Patients with chronic pelvic pain are restricted i n da ily activities a s a result o f persisting dysfu nctions i n the human locomotor system combined with psychosoc ial factors ( e . g . counterproductive beliefs , i n adequ ate copi n g strategies and dysfunctional social interactio ns ) . Because of the chronicity and complex i ty o f the pelvic prob lems of patie n ts who presen t to the SIC , a biopsychosocial appro ach offers the best possi b i l i ty for recovery. This certa i n ly seems to be the case for Maree.
• C l i n i cal
reaso n i n g c o m m e ntary
It is apparent that the initial clinical reasoning evi dent in these responses is very broad and beyond j u st the typical diagnostic/structural reason ing likely to have been applied to Maree's problems in the past. Indeed, there is obvious confidence that consideri ng the patient ' s activity/pa rticipation capabilities/restrictions, i n add i t i.on to the [actors that have contributed to the maintena nce of her problems, will resu lt in a more complete and holistic u nderstanding of the patient's presentation aDd will likely lead to an optimal resolu t ion . From previous clinical experience and from the li terature-that is, non-propositional knowledge and proposition al knowledge--the errors associated with only employ i n g diagnostica lly driven clinical reasoning with such a complex presen tation are avoided . [t is also qu ite clear that t here has already been some consid eration given to the ma nagement strategies to be employed , i ncluding the addressing of p sycholog i ca l impairments through education and empowermen t. as well as specific physical impairments.
P H YS I C A L E X A M I N AT I O N B i o m e d i cal eva l u ation Ro u t i ne blood and urine tests were negative.
N e u ro logical exam i n at i o n
(Fig. 2 1 . 2 ) . ln the case of impairment of the self-braci ng mechanism. it will be easier to lift the leg while wearing the belt. Maree was unable to perform a left active SLR because of wealmess but a p plic a ti on of a pelvic belt par tially restored her strength.
There were no signs i ndicating rad iculopathy ( e . g . asy m metri C tendon rel1exes , altered sensation in a radic u la r pa tte rn) . Load tran sfe r
The active straight leg raise (SLR) test was used to assess instability caused by a disturbed load transfer from the tru nk to the legs (Mens et ai. , 1 9 9 7 , 1 9 9 9 ) . The test is carried out with the patient in supine lying The patient is asked to lift one leg so that the heel lies 2 0 cm above the couc h . The active SLR test is positive for disturbed load tra nsfer if the patient is unable to Lift the leg or if the patient expe rie n ces diminished strength. The test is repeated while the patient is wearing a pelvic belt, which has been shown to have a stabilizing effect on the pelvis (Mens et aI 1 9 9 7 . 1 9 9 9 : Vleeming et al. . 1 9 9 5 ) .
..
Fig. 2 1 . 2
Active straight l eg raise test of the right leg.
The OS pubis on the righ t is located a few the l eft.
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mm
lower than
2 1 C H RO N I C P E R I PA RT U M P E LV I C PA I N
For patients w i th p a io i n the pelvic region . con trac tion of the hip abductor and adductor m u scles is also often p a i n ful and wea k . [n heal thy women. the mean adduction force i s 2 1 4 N . compared w i t h 1 1 7 N in the PPP patients of the SJC. whi l e the mean abduc tion forces a re 2 8 4 N and 1 8 4 N. respectively. The forces are measured w ith a s ma l l device (Microfet. Hoggan Health In dus t ries Inc. . Draper. UT. U S A ) t h a t d igital ly disp lays peak force (van Meeteren et a l . . 1 9 9 7 ) . I n this case. isometric h i p adduction was measured maxima l ly a t 5 7 N and caused p a i n in the pubic symphysis region . Isometric hip abduction was measured maximally at 1 4 6 N. Pai n provocat i o n tests
Attempts have been made to assess i mpairment of pelvic jOi n ts in a n objective man ner. b u t manual mob i li ty tes ts tend to lack i n tertester and i ntratester reliabi l i ty (Mens et a l . . 1 9 9 9 ; Potter and Roth ste i n . 1 9 8 5 ) . The most popular measurements in clin ical back a nd pelvic pain research are pain provocation tests. These tests determine the degree o f irrita tion of ligaments i n the pelvic girdle and the lumbos acral region . Two of the bes t validated provocation tests are the PPP provocation test (PPPP test) ( O stgaard et al . . 1 9 9 4 ; Potter a nd Rothste i n . 1 9 8 5 ) a n d the tenderness test for the l o n g d o r s a l sacroi l i a c liga men t (LDL) ( V leeming et a l . . 1 9 9 8 ) . The PPPP test i s performed with the patient supine and her h i p Hexed to 9 0 degrees. The patient's femur is gently pressed posterioriy by the examiner (Fig. 2 1 . 3 ) . The test i s positive when the patient feels pain in th e pos terior par t of the pelvis. Examination of Maree revealed that t he PPPP test was positive on the left side. Palpation of the LDL was painful at its PSIS attachment.
F i g. 2 1 .3 The posterior pelvic pain provocation test. ( From 6 stgaard et a l . . 1 994. p. 258. Reproduced with kind permission of the publishers.)
'b'
Active m ove m e nts
Lumbar spine llex ion demons trated loss of range of motion of abou t 20 deg rees. possibly caused by severe p ai n in the left PSIS. Lum b a r spine extension showed a s l i g h t loss of range of motion. with pain provoked i n the left gl u te a l region . Pas sive left h i p llexion and exter n a l rotation were decrea sed approximately 5 - 1 0 deg rees i n comparison with the right side. possi bly because of left-sided pubic symphys i s a n d pelvic pa i n . Hypertonia o f t h e left h i p adductors w a s detected . This was found by passively moving the leg into abduc tion : tension of the adductors could be seen a n d felt as soon as the movement was i niti ated . However. whe n Maree was asked to relax her muscles a n d the move ment was performed gen tly it was possi ble to ga i n a l mos t fu l l range.
M u s c l e asse s s m e n t
Poor recru i tment of the tra nsversus abdom i n i s mus cle was detected. This was found by instructing the patien t to perform abdom i n a'! hollow i ng i n the supine ly i n g pos i t ion. During this a ction . the tone of the muscle was palpated near its i nsertion to t h e i l iu m ( Ju l l et a L . 1 9 9 8 ; Richa rdson a n d Jul! . 1 9 9 5 ) . Assess ment of functional capacity o f the tru nk a n d pelvis was performed with t h e [sosta tion B-200 (Isotechnologies Inc . . Hill sborough . NC, US A) ( Gomez e t al. . 1 9 9 1 ) and by the use of video a nalysis (van Wingerden et al. . 1 9 9 5 ) . The B- 2 0 0 record s data on the mob i l i ty of the low back in th ree d i rections of movement. a n d also on isometric forces of t he trunk and pelvis. In order to record l u m b ar and pelvic motion . in frared markers a nd video cameras are used . Preliminary research res ults at the SJC show a d istinct lum bopel vl.c rhythm . which differs between hea l thy subjects a n d patients with low back pain . In a study of 5 7 heal thy male and female subjects. the relative contribu tions of the lumbar spine and h i p joint t o forward bend ing were mea sured usi n g the v ideo a n a lysis method ( v a n Win gerden et a l . . 1 9 9 7) . The results showed a significant homogen eous motion p a tter n . In the i n i t i al part of forward bend i n g . the l u m bar spine is responsible. on average. for 6 6 % of the motion , compared with 3 4 % for llexion of the h i p joint. T h i s indicates that in this phase of motion the a ngul a r displacemen t of the lumbar spi n e is a l most twice as fast as the angul ar rotation of the h i p jOint. In the middle part of the motion. the lumbar spine
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C L I N I C A L R EASO N I N G I N ACT I O N : C A S E STU D I ES FROM E X P E RT M A N UA L T H E RA P I STS
slows down wh i l e the hi p joint increases i ts a n gu l a r
For M a ree. the isometric torq ue streng t h of the
s peed. I n the fin a l phase of forward bend ing, l u mbar
sp i n a l a n d p e l vic mu scul a t u re mea s u red u s i n g the
motion cons t i t u tes 2 7% of the movement. compared
Isostation B-200 s h o w e d h o m ogeneous but very
with 7 3 % for hip moti o n . From the erect posture to
weak m u s c les d u ri ng Il e x i o n , exte n s ion , side bend ing
m a x imal forward b e n d i n g , the ra n ges o f mo t i o n of the lu mbar s p i n e a nd h i p j oint
are
5 8 and 54 d e g rees ,
an
b e l o w the acce p t
a b l e l eve l ( i . e . 1 0 th percen t i le of t h e v a l u e fo r healthy
respectively. Tn
and rotation . The v a l ues or t h e isometric torque s tren gth for Maree were 4 5- 6 9 %
add iti onal
s t udy
G.P.
van
Wingerde n ,
wome n ) .
Vleemin g , G .]. K leinrensink a n d R . S tocckar t ,
A.
u np u b l i s h e d d a t a ) o f 3 1 p a tients with c h r o n i c l o w
back p a i n , the c o ntri bution of the lumbar s p i n e d u r
Passive movement testi ng
in g the first p hase of foward b e n d i n g was d ecre a sed
There was red uced genera l mobil ity a nd i n c re a sed
( 5 5 % ) , whereas the contribution in the fm a l p h a s e w a s i ncre a se d (3 7 °/C ) . In t h i s g ro u p , the ranges o f
t h o racic j u n ction, mid-thoracic s p i n e. lower lumbar
motion of t h e l u mbar s p i n e a nd h i p j o i n t from the
spine a n d left sacroil i a c j o i n t ( S IJ ) . '''' h en performing
erect posture to m a x i m a l fo rwa rd 45 and
5 2 d eg rees , respectively.
� I J .
C O M M E N TA RY
D
b en d i n g were
musc u l a r tension of the upper cervical spine. cervico
these genera l passive accessory a nd phy siological mob i l i ty tests , M a ree reacted with p a i n a nd a n xiety.
REASO N I N G D I S C U S S I O N AN D C L I N ICAL REASO N I N G
What were yo u r tho ughts rega rd i ng the fi n d i ngs
Ra i S ing of t h e leg was easier t o perform with
from the physical exam i n atio n '
tened around the pelvic girdl e; this con firms that
a
belt fas
the
weakness was not ca used by ins ufficient h ip l1exor mus
• C l i n i c i an s
'
an swe r
cle action but rather by i ncreased mobili ty of the pelvic
The information fo und up to this point supported what was a l ready hypothesized from the i nterview, That i s , there w a s probably : • no
maj or
pathology
respo nsible
for
• C l i n i ca l reaso n i ng c o m m entary
• a lot of fear about the problem
PhYSical examination procedu res have been appl ied
• fea r of m ovemen t and associ ated p ain • i n s u fficient and in adequ ate use o f muscles.
What was yo u r i n terp retation of this pati e n t's active
0 . 8 3-0. 8 7 , tntertester O. 7 7-0 . 7 8 ) a n d valid (se n siti v ity 0 . 8 7 , spec i lkity 0 . 9 4 ) ( Me n s et al . . 200 1 ) .
Ma ree ' s
symptoms
EJ
j Oin ts. Impor tantly, th is test is both r e U a b le (intratester
SLR res p o n s e ?
j u d iciously to test hypotheses rel a t i n g to p hYS i c a l impairments (e.g. in adequate m u s c le action ) a n d
patient perceptions (e.g. fear of movement ) , i n addi tion to precautions and contraindications to man a gemen t (e.g. n o major pathology) . These t.ests (e.g. active SLR) appear t o have been selected on the basis
• C l i n icians' an swe r
of maximizing prin ciples , in that they provide
Im pairme n t of ac tive SLR correlates h i g h l y w i t h
a
l a rge pay off in te rm s of information relat ing to
man agement. etc. ) for
mobil ity o f the p e l v i c j o ints in p a t i e n t s with peripar
hypotheses ( impairments,
tum pelvic g i rdle p a i n (Me n s et a I . , 1 9 9 9 ) . During
relatively small cost in terms of time and effort. The
ra i s i n g of the l e g , the hip bone o n the tested s ide i s
h igh reliability and validity of these tests , such
fo rced t o rotate a n teriorly abo u t a horizo n t a l axis
the active SLR, is importa nt because it reduces the
nc a r the SI] (counter-nutati o n ) . In the case of Maree,
l ikeli hood of reason ing er rors and thus
t he tes t w a s positive on the left side, s o i t may be con
accu racy in clinical decision making. Emcient and
cluded that the mobility o f the l e ft hip bone d u ring
accurate clinical reasoning, such as demon strated
a n terior rotation (and t h u s the SID was i ncrease d .
here, is typical of t h e expert prac titioner.
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a
as
e n h a nces
21 C H RO N I C PE R I PART U M P E LV I C PAI N
C u rre nt rad i ograp h i c re p o rt
I n 1 9 3 0 , Chamberla i n i n trodu ced a method to visual ize SIT mobi lity radiographically. He showed that smal l rotatory displacements of the pelvic bones about a tra n sverse axis a re not demonstrated on a n teroposte rior roentgenograms. He described how movement of t he SI} is best determined by measu ri n g the movement between the pu b ic bones w i th alternation o f weight bearing from one leg to the other. Later. Berezin ( 1 9 5 4 ) compared women i n t h e puer peri u m w ith a n d without pe l vic pain compla ints . He measured a shi lt between the pu bic bones of 5 . 9 ::'::: 3 . 3 mm i n women with com p la in ts a nd 1 . 9 ::'::: 2 . 2 m m in those without. The radiogra phic report for M a ree stated t h a t the pu bic sym physis s h owed smooth delineation of the j o i n t su rfaces, w i th a j o i n t width of 4 m m . There wa s sc lerotic subc h ond ra l bone on the left pu b i s . When stand i n g o n the left leg with the right leg hanging, the left a nd right pubic bone heights were symmetrica l . W h e n s ta n d i n g on t h e right leg with t h e left l e g h a ng ing, the left pubic bone was 2 mm l ower than the rig h t ( Fig. 2 1 . 4 ) . VVhi le sta n d ing o n both legs, t here w a s n o ' step ' between t h e p u b i c b o n e s , b u t t h e right femoral head was 4 mm lower t h a n the left . The SIJs, lumbar spine and h ips s howed n o abnormal i ties. L u m bopelvic rhyth m
Video a n alySis (va n Wingerden et a I . , 1 9 9 5 ) i n the standing posi tion revea led a n a n terior pelvic tilt with i ncreased thoraco lu mbar lordosis. During forward
f'"
bending, the average c o n tribution of the lu mbar spine during the fi r st phase was 6 1 'X" whic h is sligh tly less than tha t fou nd i n the h ealthy popu latio n . In the fi nal phase. however. t h e contri butio n was 4 7 % , whi c h is ma rkedly g reater t h a n the 2 7 ' Yr , con tribution shown in the healthy populatio n . T h e ra n ges of motion 0 1 the l u mbar spine and hip joint fro m the erect posture to m a x i m a l forward ben d ing was 6 8 and 4 9 degrees, respectively, which i n d icates a relatively mobile lum b ar s p i n e b u t d i m i nished hip mo b i lity. Psyc h o s o c i al eval u ati o n
M a ree presen ted a s a tense, emoti ona l ly sensitive wom a n who fel t she c o u ld not ' co pe a ny more' a n d w a s s i mply overw helmed . Her a n x iety a n d i na b il ity to cope was fur ther agg ravated by the fa i l u re of p rev ious single- moda lity treatments, the recent exacerbation o f her pain a n d h e r i n ability t o work as a make-up a r tist. She avo i ded activities o r s i tuations that might c a u se p a i n , that is her pai n was rel a ted to fear. With her g ra d u al withd rawal from social activi ties, she bega n to fee l i ncreasingly helpless and hopel ess . S i nce the o nset of p a i n , s h e had n o t been a b l e to have sex u a l contact with her h u sb a n d . Because of renovations at h e r home that too k l o n ge r t h a n pl a n ned , IVIaree w a s o b l iged t o m ove h o u s e several ti mes , w h i c h caused her considerable s tress a n d . in t u r n , i n tensilled her sym p toms . Maree pa id for house hold help for 4 h o urs a week. Pa i n re l ated t o fea r of m ove m e n t
Excessive pain-re la ted fea r o f movemen t w a s meas ured with the Tampa Scale for Ki nesiophobia (TSK) (Kori et aI. , 1 9 9 0 ; Vlaeyen e t a I . , 1 9 9 5 ) . The degree of fu octional restriction is described i n terms of experi enced phy s ical inj u ry, fear of i n j ury, fear o r re- i n j u ry, importance of mobi lity a n d the degree of measu red p hysical activity. The TSK score of 5 1 i n d icated intense pain was rela ted to fear of certa i n movements. Psyc h o l ogical testi ng fo r m a ladj ustm e n t
Fig, 2 1 . 4
Ra d i ogra p h of pat i e n t sta n d i ng on the right
l eg with the l eft leg ha ngi ng. The l eft p u b i C b o ne i s 2 I<;>we r than the right.
mm
T h e preseoce of psychopathology was eva luated w i t h the Symptom Check List 9 0 ( SCL- 9 0 ) . This is a multi d imensio nal complaint list that describes the presence and degree of eight psyc h ological dimensions (e.g. fea r, depression, hostility, etc. ) , as weJ l as providing a total score that describes the general psyc h o neurotic para meters ( Arinde l! and Ettema, 1 9 8 6 ) . The SCL- 9 0
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C L I N I C A L R E A S O N I N G IN ACT I O N : CASE ST U D I ES FRO M EX P E RT M A N U A L T H ERAPISTS
res ults s howed Maree scored high on depression, feelings of insufficiency and sleep disturb ance. In addi tio n , the overa ll score for psychoneuroticism was high.
Pa i n , d i sab i l i ty, and e n e rgy l evel The Visual A n alogue Scale (VAS) pain score, a valid self-report measure of pain i n tensity (Down ie et a l . . 1 9 7 8 ) . was 8 9 m m . indicating a n intense sensation of pai n . The McGill Pain Questionnaire , Dutch Lan guage Version (MPQ-DLV) (van der Kloot et a I . , 1 9 9 5 ) . wh ich is a reliable and valid version of the McG ill Pain Questionnaire. was used to measure pain fu rther. It comprises questions related to the l ocation of pai n . cou rse o f p a i n , i n fluence o f p a i n on the quality of daily l i fe, a VAS pain rating, and a list of 20 groups of adj ec tives that are used to describe the senso ry,
a ffective and eva l u a tive d imensions of pain. Maree 's MPQ-DLV pain rating i n d ex was 2 9 , which sugges ts that the p a i n had a strong i mpact on her quality of l i fe. T he degree of disability was measu red with the Dutch version of the Q uebec Back Pa i n Disab i l il'y Scale (QBPDS ; Sc hoppink et a I . , 1 9 9 6 ) . This sel f-reported scale was originally develo ped to measure the disabi l ity of patients with non-spec ific low b ack pain. but it has also proved suitable for patients with PPP. Twenty items a re scored on a six-poi nt scale ranging from ' not difficult' to ' impossible to perform ' . Maree 's score was 8 9 , suggesting that she felt marked ly limited in all aspects of her daily life. The VAS for energy level was 9 0 . i nd ic a tin g a major reduction in energy capaci ty.
R E A S O N I NG D I S C U S S I O N A N D CLI N I C AL R EAS O N I NG C O M M E N TA RY
D
W hat significance d i d you place on the radi ological findings?
• Clinicians' answer The radi ographs of Ma ree s howed i n c reased mobility of the left i l i u m in an a n terior d irection (counter-nutation) . a s indicated by the asymmetries be tween the pubic bones and between t he femoral heads. These findi ngs were consistent with the worki ng hy pothesis (insuffiCient and i n adequate use of muscles. associated with fear of moveme nt a n d fe ar o f p a i n ) a n d with the resu l ts of the active SLR tes t.
at the same time was completely out of touch with it. These factors demonstrated that Maree's physical dis ability was not merely a consquence of tissue damage . Maree cou ld not ad equately contract the muscles of the tru nk a n d hip in order to ach ieve an adequate load transfer. Furthermore. achievemen t of rel ax ation and correct tension does not occ u r at the time at which these cha nges i n muscle tension are required . PhYSica l exa mi nation t1ndings from the Isostation B-200 test ing. video ana lysis and run ctional tests or load transfer are all consistent with this hypothesis.
D
Maree's clinical presentation appears to be quite complex. W hat pathobio logical
D
mec hanisms did you hypothesize were
W hat was your judgment of Maree's muscle
underpinning her problems?
control (awareness and function) ?
• Cl inicians' answer
• C linicians' answer Ma ree demonstrated a rigid posture ca used by tense muscles related to improper load tra nsfer and beca use of defensive emotion al patterns. She fe lt un accepted . n o t take n seriously and disco n nected. She was unable to ex press her emoti ons and disp l ayed minimal sensory-motor awareness as if ' she lived out of her body ' . It was a lso striking that Maree was complete ly preocc upied with the appearance of her own body a n d
Mechanisms related to pain and tissues can be iden ti fled .
Pathobio logical mechan isms related to pai n . From the cli n ical findings, some patterns emerged that were su ggestive or central sensitization of pain responses. that is a change i n the sen sitivity state of the cen tral nervous system (Gifford and Bu tler. 1 9 9 7) . These included perSistent and inconsistent
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21 C H RO N I C P E R I PA RT U M P E LV I C PAI N
p a i n p atterns. pain responses to i nputs that would not normal ly provo ke pa i n . and a reactive latent p a i n response to certain activities . The persista nt ongoing pelvic pa i n of this patient was not simply a result of mec h a nical SII dysfuncti o n . T h e tissues of t h e lumbopelvic region probably rema ined in a hypersensitive state through lack of use caused by movement a nxiety. rather than because of sign iflca nt tissue da mage ( G i fford . 1 9 9 8 ) . It is very l ikely that this excessive sensi tiv i ty he lped to m a intain the tissues i n a weakened state.
Pathobiological mechanisms related to tissues.
II
What physical i mpa irments and patient perspectives (with respect to potentia l unhelpful psychosocial issues) did you think were of part i c u l a r c l i nical Significance? Could you esta b l ish a diagnosis?
control over her body or-even worse--over her own life. Problems of adaptation to the new situation and acceptance of things 'as they are ' existed i n relation to the pa i n . which originated during pregn a ncy. They were man ifested as anger. fear. disappointment and feeUngs of fru stration. Although there was no question of serious psychopathology. the scores o n the psycho social scales indicated the marked emotional i mpact of her present situation. The pathobiological mechan isms related to pain cause add itional anxiety because she was unable to fathom her own disease process. Moreover. she felt entangled i n maladaptive t houghts and emotions as a result of the persisting pain. It has been demonstrated that positive or ' helpfu l ' psycholog ical states have a beal thy biological effect at many physiological levels (Butler. 1 9 9 8 ) . It is probable that the depressed mood and other mal adaptive alterations in psychological function were largely the result o f her pain state having a direct effect on her behaviour.
• C l i n i c i ans ' an swe r T h e following impairments were of particular clinic a l s i g n i ficance: In terms of physical i mpairment. the diagnosis o f P P P (Me ns e t al. . 1 9 9 6 ) was established based on t h e fo llowing typical assessment find ings (and based o n t h e l oad transfer model) : • the pain bega n during pregna ncy • the pain was located in two o f the j o ints of the
pelvic girdle • abil ity to perform activities of d a i ly livi n g was
reduced • there was no maj or pathology • t here was disturbed pelvic load transfer shown by:
- reduced active muscular stabilization of the l umbopel vic regi o n - positive active SLR test on t h e left side - the PPPP test and pa lpation of the LDL were positive • sig n i ftca n t radio logic a l findings. The occu rrence of psychosocial impa irment was indi cated because the description of the compl ain ts a nd the exten t of the activity restrictions could not be explai ned by d isturbed load transfer a lone. From a biopsycho social perspective. it is known that the factors maintain ing pain can d i ffer rrom the initiating factors (Vlaeyen et a l . . 1 9 9 8 ) . In view of the particularly high psycho social test resu lts. th is patient could be descri bed as being emotionally 'out of balance' a nd no lon ger with
D
Cou l d you please discuss the stabil i zing m echanisms that you considered were of importance in understanding this patient's prob lems and in deter m i ning appropriate physical management?
• C l i n i c i an s' an swe r U nder postural load. specific Ugament a nd muscle forces are i n tri n Si c a l ly necessary to stabilize the pelvis. Load transfer from spine to leg passes through the SIJs. helping to stabilize these jOints effectively. This can be explained by a model of load transfer of the pelv is (Vleemin g et a ! . . 1 9 9 3 ) . Effective force transfer that withstands the shear forces of the Sr] is provided by a combination of speci fic a n a tomical features of the SrI (form closure). such as the wedge-like and propel ler l ike form of the jOint surfaces and the high friction coef ficient (Pool-Goudzwaard et al. . 1 9 9 8 ; Vleemi n g et a l . . 1 9 9 3 ) . Orchestrated forces generated by muscles. liga ments a nd faSCia a lso prevent shear forces by mea ns of compression. which can be adj usted to the specifLc loading situation (force closure) ( V leemi ng et a l . . 1 9 9 5 ) . This model h a s been vaUdated (Sturesson et ai . , 2 0 0 0 ) a n d i s frequently used to investigate impaired lumbopelvic function. It can be helpfu l in identifying abnormal movement patterns i n the pelvic girdle a nd in establ ishing their clinical consequences. For instance. the model predicts that when the pelvis is loaded in a standing positio n . the pelvis genera l ly
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C L I N I C A L R E A S O N I N G I N ACT I O N : C A S E ST U D I ES F RO M E X P E RT M A N UAL T H E RA P I STS
becomes self-locked with a sma ll rotation
of the sacr u m
n o d d i n g a n teri orly relative t o t h e i l i a ( n u tation ) . Lax ity
of pelvic l i game nts and a p a i n fu l pubic sy m p hysis leads to a n avoida nce of nutation (espec i a l ly d uring preg nancy).
w i th Maree
' c hoosi ng'
a counter-nutated
position
of the srI that d isengages the self-lockin g
mechan ism of the pelvis ( V l eeming et al
. .
1995).
New i n form a t i o n has been reported o n the stabi l i ty of the lumbopelvic region a n d d i s t u rb a n c es or motor control. nota bly a ffecting the segme n t a l s u p porting c a p a c i ty of the deep muscles of the
ab
d ome n and
back (J u l l et a l . . 1 9 9 8 ) . There is e v i d e n ce t h a t a par tic u l a r exerc i s e programme a i med a t
re-ed u c a ting
p a t i e n t s with c h ro n i c low back pain to activate the deep muscles spe c i l1 c a l ly c a n i n ll u ence the motor con trol strategies o f these muscles (Ju l l e t aJ . . 1 9 9 8 ) .
fi n d i ngs: i t also req uires ski l led n a r ra t i ve and d iag n ostic reaso n i n g st rategies.
as
d i scussed in Ch apter 1 .
T h i s d i scLlssion o r the com plex i n ter-relation s h i ps o r physical
and
psyc hoso ' i a l
factors in
'Maree ' s pre s e n t a t i o n p rov ides evidence o f the abil ity of the expert c l i n i c i a n t o t h i n k simu l l a neoLlsly at
the
micro and macro leve l s . a n d across several
hypothesis categories ( e . g . p a t i e n t s perspect ives or '
their experi ence. physic a l i m p a i rme nts a n d assoc i a te d sources. c o n tri b u ti n g fa ctors. p a t h o b i o logical mec h a n i s m s , etc. ) . While collecting a n d sy n t hesiz
i n formati o n ) , the
ing spec itlc c l i n i c a l data ( m i cro
c l i n i c i a n needs to interpre t t hese data i n t he l i g h t
o f t h e l a rger biopsychosocial pict ure. p a r t i c u la rly the p a t ie n t ' s acti v i t y a n d p a r t i c i pation rest rictions ( m a cro i n formati o n ) . It i s also appare n t that the c l i n i c a l reason i n g i n
• Clinical reasoning commentary
t h i s case h a s been l a rge ly driven by the recog nition
The recog n i tion of the rel a t i o n s h i p between this
recogn iti o n process. Key p hysical a n d psyc hos oc i a l
of fa m i U a r cli nical patte rn s . that is. by
patie n t ' s physica l prese ntation a n d psyc h o l ogical present.atio n .
as
postu re. move
ma ni fe st i n her
m e n t p a t t. e r n s and her sensory-motor awaren ess,
biopsychosocia l reason i n g n eeded i n of i n formation a n d u n dersta ncling is dimcult to cap t u re s i mply by giving an acco u n t of exa m i n ation
a
pattern
features of PPP have been iden t i tled in M a ree's clin i c a l presentation by re l a t i n g c l i n ical fi n d ings to prototy pe stored in the c l i n i c i a n 's memory. T h i s
a
has
i l l u stra tes the
occ u r red for both the diagnostic syndrome of PPP
con temporary m a n u a l th era py. Such b r e a d t h
and the associated pathobiological mec h an isms/
[3;"'f'49" '9"Maree met the inc lusion cri teria for a dmission
to the
SIC re habilitation programme . A fter considering i n for mation from a range of so urces (e.g. patient i n terview.
p hysic a l examination. test resu lts, pub l i shed l i terature, and ' g u t feel i n g ' ) . s pecific physical dys fu nctions and emotio n a l int1u ences were identi fied ,
a s were the
soc i a l consequences ( B u tl er. 1 9 9 8 ) . To address these fac to rs. it was clear t h a t a comprehensive man a gement approach n eeded to be i mplemen ted . Accord ingly. the goa ls o f management were to enable Maree to: • i mprove her pelvic force cl osure
in order to facili
factors contrib uti n g to t he maintenance of the patien t ' s prob l em s
------.
• res u me a n ormal. func tio n a l l i fe. inc l u d ing returning to work • take c o n trol of her l i fe • reduce or better use of health-care services. At the SJ C, physical therapists . ma n u a l therapists
( phys i c a l thera p i s ts who have undertaken fur ther education in ma n u a l therapy ) , psychologists an d p hys i c i a n s collaborate to deliver
a
comprehe n s ive pro
g r a mme v i a group therapy for 3 hours twice a week for 8 weeks . I n i t i a lly, the patie n t is prov ided
with pain
a n d s leep medication to ensure that p a i n comp laints are reduced to an ex tent that enab les effec tive partici pation i n the programme. The progra mme initia lly
of the self- braCing mech for the SIj and . therefore. the devel opment of
t a te self-bracing of the pe l vic girdle. thro ugh a ppro
commences with restora tion
pri ate exercises and re-ed u c a t i o n of moveme nt
a n ism
p a tter ns
stabi lity for the l u m b o pelvic reg ion. S e l f-bracing of the
• i m prove her genera l cardiovascu l ar condition so as • e n h a n c e her abi l ity
to m an age and c o p e w i t h her
pain and re l a ted problems
SI} i s ach ieved by developing optim a l biomechanics for this j o i n t ( V l a eyen et a l . . 1 9 9 8 ) . Dimi n i s hed nutatio n ,
to preve n t fu rther decond i t i o n i n g
o r relative counter-nutation o f the sacru m , reduces self-brac i n g of the SrI and may lead
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to insta b i l i ty. It may
21 C H RO N I C P E R I PA RT U M P E LV I C PAI N
LDL a nd a n
a lso produce add i tio n a l tension in the
altered load-beari n g capacity of the j o i n t s u rfaces, and hence dysfu nctio n . It is kn own that artic u l ar dysfunc tion rapidly leads to i n h i b i t i o n o f s low- twitc h musc le Ilbres. which may resu lt in red u ced abi l ity of muscles to sustai n a contracti o n ( Le e ,
1 9 9 7 : V l aeyen e t a l . . 1 9 9 8 ) .
I t i s also known th a t exercises alone w i l l n o t bring about
a
successfu l reso l u t i o n i f the S I] has become
chron i c a l ly comp ressed in a c o u n ter- n u t a ted pos i t i o n .
In these p a t i e n t s . a speci fic m o b i l ization techn ique is
F i g. 2 1 . 5
M o b i l izati on of the l e ft sac ro i l i ac j o i n t u s i ng
isometric h i p exte n s i o n con tracti o n aga i n s t a belt.
Ilrst a p p l ied a nd the muscu l a r system then u t i lized to
fo u r-stage
ma i n t a i n opti m a l j o i n t mec h a n i c s ( Don Tigny. 1 9 9 7 ) .
Richardson a nd J u ll (Ju l l e t a l . .
I n i ti a l ly
programme
deve l o ped
by
1 9 9 8 : R ichardson a n d
progranune,
J u l l . 1 9 9 5 ) was a p p l ied. Retra i n i n g of the pos terior
articul ar dysfu nctions were mobil ized . In this tech niq ue.
oblique. an terior o b liq ue. and longitud i n a l musc l e sys
the S lI dysfu n ction can be cor rec ted by mobi l izi ng
tems. as described by Vleem i n g et a l . ( ] 9 9 5 ) . was i n te
in
Maree's
sta b i l ization
rehabi l i tation
the i n n omi n a te bone posteriorly a n d dow n wa rd o n the
grated i n t o this prog ra mme. Ma ree
s acr u m . by u s i n g t h e leg
i n capaci tated . p hysi c a l l y cl eco n d i L i o ned and fu nction
as a
lever. by g raspi n g the
was a l s
o severe ly
i n nominate bone d i re c t ly and rotating. or even by
ing a t a low activity level ( S horland. 1 9 9 9 ) w i th i nem
using
cient use o f energy. To i mprove her overa l l condition
a
stron g isometric hip extension con traction
aga i n st a be l t ( Fig. 2 1 . 5 ) . Fol l ow i n g the mobi l ization.
a n d c a rd iovasc u l a r Il t ness. aerobic exerc i s i n g was
stre n g t h and endurance of the weake ned muscles was
applied at each treatme n t sess i o n . The relevance of
addressed . The a i m was to re activate the stab ilizi n g
improved fi tness and p hysica l fu nctioning wi t h respect
muscles. particu l a rly t o retrain their holdi ng capacity
to pain was not e n t irely clear to M aree. However. the
and their abi lity to contract appropri a te ly w i th other
fac t that i mprovement in her overall p hysical fu nction
synergists . in order to support and protect the l u mbo
was l inked to improvement of her psychosoci a l fu nc
pelvic g irdl e u nder v a r i o u s functio n a l
tion was clearly e v i d e n t to Maree.
� I J ..• D
loads. The
R E A SONING D I SCUS S I ON A N D C LI N ICAL R E A SONING COMM E NTARY
Assisting patie n ts to transform thei r
30 m i n u tes e a c h were reserved for th i s aspect o f m a n
understanding of thei r p roblems. a n d the
agemen t . They i n c l uded lessons d e a l i n g w i t h t h e
various contributing factors, is clea rly an
a n a to my a nd fu nc tion o f t he back, ergono mics , a d v ice
important as pect of your management. Coul d you please comment on how this was specifically addressed in M aree's case?
aspect
of
the
a nd sexu a l i ty. There is l i ttle evidence to s uggest a l o n g-term a dv a n tage of a ny particular psych o l og i c a l approach
• C l i n i cians' answe r A n o t her
abo u t activities of d a i ly l iv i n g . pelvic tloor tra i ning
to d i sabi l i ty ( Waddell. i n teg rated
1 9 9 8 ) . A combin ation o f cog n i
m u l tifactori a l
tive, behavi o u ra l a n d psychophy s iologica l tec h n iq u e s
approach is t o make patients aware of the importance
a r e u sed to man age p a in . T h e a im is not to r e d u c e p a i n
o f their o w n ' e mpowerment' . In the case o f Maree, we
p e r s e b u t rather t o develop t h e patie n t ' s respo n s i bi l i ty
u sed edu catio nal lessons. enh a nc i ng her knowledge
for t h e i r own p a i n and to help them to con trol a nd
a n d u n dersta nd i n g o f her cond i ti o n , thus e n a bli n g her
manage it ( G a tc h e l a n d Tu rk . 1 9 9 6 : Wadde l l .
to deal with her own pain and disab i l i ty better a nd to
T h i s i s m a i n ly a c h i e ved by c h a n g i n g the p a t i e n t ' s
1998).
cope with stress . Ma ree requ ired spec i llc and relevant
beliefs a nd misu ndersta nd i n g s abo u t c hr o nic p a i n .
i n formation to assist her in m akin g choices , over
Cli n i c ally, i t p roved h e l p fu l t o ex p l a i n t o Maree that the
comi ng nega tive b e l i e fs a n d mod i fy i n g h er b e h aviour
excessive sensitivity o f her l u mbopelvic region was a
(e.g.
problem i n i ts o w n r i g h t , a n d t h a t her p a i n was n o t
incre a s i ng
her activ i ty) .
F i fteen
sess i o n s o f
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C L I N I C A L R EA S O N I N G I N ACT I O N : C A S E STU D I E S F RO M EX P E RT M A N UA L T H E R A P I STS
caused by tissue d a mage alone. It was impor tan t to ens ure that Maree did not o n ly equ ate pain with dam
age and fear of movem e n t (Mens et a I . , 1 9 9 6 ) . Maree demons trated
a particular behavioural pa ttern as a
res u l t of maladaptive thoughts a n d emotions centred
aro u nd her pain. To ad dress this issue, she wa s i n formed th a t general immobility leads to a loss of muscle s t re ng th coord ination , stability and muscular ,
and physical endurance (Main and Spans wick, 1 9 9 8 ) .
In the ma nagement prog ramme, the principle of ' movement for enjoyme n t ' was stressed ( McIndoe, 1 9 9 5 ) . To help to motivate Maree. the essential pri n c i ples of trad itio n a l yoga were explained , includi n g
daily practice. Maree received
• Clinical reasoning commentary Where
of
managemen t
p hy s i c a l
impai rmen t
requires ' i nstrume n t a l action' ( e . g . mobilization
a n d motor retrai n i n g ) . man agement of p a t i e n t s '
perspectives j ud ged to be pot.e n t i a l o bs t a c l es t o t h e i r recovery such a s u n helpful beliefs a n d feel
i n gs
requ i res
'c ommunicative
action '
d i rected
toward wo rk i n g with the patient to cha nge their per spective s As d i s c u s se d in Chapter 1 c h anging these perspec tives is n ot easy a n d n ecessi tates skilled interaction to assist t he patie n t to renect on .
,
the b a s i s of their bel iefs . S i mple. one-off expl a n
home-based exercise
a t i o n s are rarely su ff1cient. as evidenced i n t h i s
programme, comb i n i n g daily practice a n d enj oyment
c a s e b y the t i m e a n d effort the c l i n i c i a n s devoted to
a
or movement with stabi lizati o n , breat h i n g , stretchi n g
a n d stre n g t he ni n g exercises. These exercises we re
addre S S i n g
the
p a t i e n t 's
u n d erst a n d i ngs
,md
b eliefs . However. when successfu l l e a r n j n g does
checked eac h visit and it was stressed th at her role was
occu r,
as importa nt (or even more so) as that of the therapist.
a l l o w i n g them to m a ke better decisions. Critic a l ly.
In one of the l ast session s . the importance o f m a i n taining a lTa i n i n g programme in a s u i table fitness or yoga centre was expla ined . Maree was al so advised
patien t s '
t h i s dimension of
perspectives re a
a re
transformed ,
s o n i n g and management
is
most successful whcn c o n d u c t e d coll aboratively.
The c l i n i c i a n s ' r e fe r e n ce here to hel ping ' t o assist
o n a plan o f action in case o f exacerbation s . It was
her i n making ch oi c e s i l l u strates t h e i r collabora
emph asized that a n exacerbation should n ever be
t ive reaso n i n g ap p roa c h
'
.
seen as a fa il u re or as evi dence of her inability to man age the cond i tion; it is merely a challenge of self management, not the end of i t .
O utco m e
exploded into a serious pain and disability problem t h roug h a combination of biopsych osoc ial fac tors. This
A t t h e e n d of the t h er a peu tic programme, M a ree
complexity is not usua Uy we l l recogn ized in routine
still
clin ical practice. Partially as
experienced
some pel v ic p a i n : however,
her
a res ult of single-moda Uty
coping mechanisms were g reatly imp rove d . She fe l t
treatment in the past. Maree felt that she had lost con
less restricted i n h e r daily activ i t i es a n d h a d more
trol over her body, t h e pain and her own life.
c o n trol over her life. She was motiva ted to co n t i n u e
During t h e therapy, she star ted to see hersel f as
tra ining in a fitness centre u n til she fe lt like ' h e r old
c hangi n g from a pa tien t with c h ronic pelvic pain to a
self'
a ga i n .
whole person again . S h e realiz ed the fu tility of waiting
The T S K score w a s now 3 6 , i n d i cat i ng t h a t there
fo r someo ne else to mal<e t h i ng s better for her. The
was markedly less fear of movement, and the score on
management programme helped her to d iscover the
the QBPDS was 2 8 . su ggesti n g th a t she no lo nger had
u n derly ing complex ities of p a i n and i ts physical , emo
any maj or limitations in d i fferent aspects of her daily
tiona l and psychosocial impl ications. This in formation
l i fe. The VAS p a i n score was 2 2 , i nd icati n g only a mild
also prompted perso n a l development for Maree. She is
sen sation o f pain, and the VA S energy level score had
now able to view herself as a whole and connected
greatly i mproved to 3 4 .
being. After the rehabil itation progra mme. s he no
B y means of this
multifacto rial ap p roac h the go als .
longer expects a total cure, i nstead she has tal(en con
for this patient were ach ieved. She presen ted to the
trol of her l ife . She can now decide where she wants
clinic with l u mbopelvic pain that h ad become 'out of
to go and what she wa nts to d o : a clear sign of good
control ' . A relatively minor load transfer problem had
health .
Copyrighted Material
2 1 C H RO N I C P E R I PA RT U M P E LV I C PAI N
fig
REAS O N I N G D I S C U S S I O N AND C L I N I CA L R EAS O N I N G C O M M E N TA RY You appear to attrib ute some of the
learns and bu ilds a kn owledge base by retlecting
responsibility fo r M aree's problems to previous
u pon each c a se , such that over a p e riod of time
practitioners who were arguably more na r row in their man agement approach. Clearly, however, m ost patients do not go on to develop c h ronic pain and related psychosocial problems. What warning signs might have alerted these
n o n -propositional knowledge, there is t h e d a nger
practitioners to the likelihood of Maree failing
that
to respond to their treatment or perhaps
in appropri ate or ineffective treatmen t may be
prolonged , po t en t i a l ly contrib uting to the devel op
actually worsening because of it?
ment of chronic p a i n or illness perspec tives and
• C l i n i cian s ' an swe r Ineffectiveness of thera py. or
a
a p a r ticular clinical syn drom e is embe d ded within their memo r y, includ ing the associ ated expected or usual re sponses to various i n terventions. Wit h o u t th i s experienti a l prototypical templ ate of
behaviours ( e . g . passive coping with dependence o n others to solve the problem, pain -cen tred m a l a
poor res ponse to treat
ment, is proba b ly t he key i n d i c a tor o f poten tia l long term pain or psychosoci a l pro b lems. The exper i enced
a d ap t ive
beliefs a n d be h av iou rs ,
delayi n g of t h e imp lementation of
ate
etc . ) and t h e more appropri
man agement. Non -expert clinic i ans often fall
a
i n to the trap of persisting with interven tions that
typ ic a l presentation w i l l respo n d to a parti c u l ar th er
are i neffec t ive i n the longer-term either because
apy. If the prob lem does not respo nd as a n ticipated ,
they l a ck the clinical experience or because they
c l i n ic i an h a s
an
expectation as Lo how
a
patient w i t h
then the ' good' cl i n ic i an w i l l recog niz e this as a ' n a g ' i ndicating t h e poss i bili ty of m o r e
serious
or complex
problems . It is impo r tan t t h a t c l i n ic al tes ts and evalu
h ave failed to learn from their cl i nic al experiences suffic ient to recognize t he atypical response. Evidence-b ased
practice
provid e s
impo r tan t
ation instruments are s u i tably re levan t and sensiti ve to
gu idel i nes to practice, but not ' recipe ' solution s .
fac ilitate the early identification of n o n -responsiveness
Skilled clinical re a soni ng is essential t o app ly those guidelines. Appropriate reassessm e n t , a s the c l ini cians h ave highlighted here, is the mean s by wh ich
to treatme n t . Re assessment fo llowing the ap p lic a tion o f a n i nter ven t i on is crucia l . as is the rec ogn ition of the need to c h a nge tre atmen t a ppro aches when the
the optimal manner and dosage of the interven
o u tcome is less th a n desired .
tion is determined and the c l i n ical validation is made. Impor tantly, wh ile reasoning a nd interven tions d irected toward p hysical impairments are
• C l i n i cal reaso n i ng c o m m e ntary The
reassessed t h ro u gh obj ective outcome measure
importance of rel e v a nt clinical experience in
ment,
commu nicative
management
directed
the recogn itio n of atypical re spon ses to treatmen t
toward p a ti e n t perspectives , such as their b e liefs
is evident in t h i s an swer. T h e exper t clinician
and
fears,
must also be reassessed .
• Refe re n ces Arinde l ! . W A . and Ette m a . H. ( 1 9 8 6 ) . SCL-9 0 : H a n d l c i d i n g b i j
cen
M u l tidimensionele Psyc hopathologie Indicator. L i s s e : Swets and Zei t l i n ger. Berezi n . D. ( 1 9 5 4 ) . Pe l v i c i n s u mciency du r i n g pregnancy
a n d a fter
Berg. G . . H a mmar.
M. and MoUer-Nielsen. J. ( 1 9 8 8 ) . Low back p a i n d u ring pregn a n cy. Obstetrics a n d Gynecology. 7 1 , 7 1- 7 5 .
Butler. D. ( 1 9 9 8 ) . Intro d uction.
I n tegrating pain awareness in to
parturitio n . Acta Obstetrica et
physiotherapy: wise action for the
Gyn ae co lo g ic a Scand i n avica .
fu ture.
2 3 . 1-1 30.
W hi p l a s h-Science and Man agement.
In To pical I s su e s in Pa i n 1
Copyrighted Material
Fear-avo i d ance Beliefs a n d Be h a v i o u r
(L.S. Gifford. e d . ) pp. 1-2 3 . Falmo u t h . U K : C N S Press . Chamberl a i n . W. E . ( 1 9 3 0 ) . The symphy s i s pubis in the roen tgen
e xa m i n a ti on o f the s a cro- i l i ac j o i nt. American Jou r n a l o f Roen tgen o logy. Radium Th e r a py and
Nuclear
Med i c i n e . 2 4 . 6 2 1 -6 2 5 .
C L I N I C A L R EASO N I N G I N ACT I O N : CASE STU D I E S F RO M E X P E RT M A N U A L T H ERAP I STS
Don Ti gny.
R . L. ( 1 9 9 7 ) . Me c h a n i c s
a nd
trea tment of t h e sacro i l i ac j o i n t . in
Low R a c k Pa i n ( A . V l e em i n g. V Moo n ey. T. Dorma n . C . S n i jders a n d R . Stoekart. ed s . ) pp. 4 6 1-4 7 7 . Ed i n b u rg h : C h u rchi l l Uvin gstone. Down ie. W. W. . Le at ham. PA . . R h i n d . V. M . el a L ( i 9 7 R ) . S t udies w i t h p a i n ra t i n g scales. A n nals of t h e Rheumatic D i s e ases . 3 7 . 3 7 8- 3 8 l . Fa s t . A . . S h a pi ro . D . . D u c o m m u n . E.J. e t a L ( 1 9 8 7 ) . Low back pa i n in pregn a n cy. S p i n e . 1 2 . 3 6 8-3 7 l . C a tcheL R . I . a n d Turk . D . C . ( 1 9 % ) . Move m en t Stab i l i ty and
Psy c h o l o g i c a l Appro a c h es t o Pa i n M a na gemen t. N e w Yor k : G u i l rord
Pu blicat ions.
G i fford . L . S . ( 1 9 9 8 ) . Tiss u e and i n p u t re l a t ed mech a n i s m s . in Topical Issues i n Pa i n I Wh i p l a s h-Sc i e n c e and M a nag e m e n t. Fea r-avo idance Re l i e fs a n d Beh a v i o u r ( L. S . Gi fford . ed . ) pp. 5 7-6 5 . Fa l mo u t h . U K : C N S Press. C i fTord. L.S. a nd Bu tler. D . S . ( 1 9 9 7 ) . The i n te g ro t ion o r p a i n s c i e n c e s i n to c l i n i c a l proctice. Hand Therapy. 4 . 8 6-9 5 . Gomez, T. . l3ea c h . G . . Cooke. C . e t a l . ( l. 9 9 1 ) . No rm a t i v e data l'or tru n k ra nge o f Ill o t i o n . strength. velOcity a nd e n d u r anc e w i t h the i sosta t i o n B-200 l u m bar d y n a m o m e ter. S p i ne. I n . 1 5- 2 ] .
G . A . . Scott. Q. . Richardso n , C. et il l . ( 1 9 9 8 ) . New c o n c e p ts lor the con trol or p a i n i n the l u m bopelvic r e g i o n . In T h i rd In terd i s c i p l i n ary World Co n g r es s on Low Back a n d Pe l v i c Pa i n ( A . V l eeming. V. i\!I oon cy. H . T i l s c h e r et 3 1 . . eds . ) pp. 1 2 8- ] 3 2 . Rotterd a m ECO. Kori , S . H . . M i l ler. R . P. a n d Tod d . D.D. ( 1 9 9 0 ) . Kinesiop hobia : a new v i e w of c h r o n ic pain b e h a v i o u r. Pa i n M a n agement. 1 . 3 5-4 3 . Lee . D. C . ( 1 9 9 7 ) . Treatmen t of pe l v ic i n s t a b i l ity. I n Movement S ta b Ui ty a n d Low Back Pa i n ( A . Vleem i n g. V. M oo n e y. T. Do r m a n , C. S n i j d e r s and R . Stoek ar t . eds . ) p p . 44 5-4 h O . Ed i n b u r g h : Ch u rc h i ll Livi ngston e . M a i n , c.J. a n d S p a n s w i c k . C . c . ( 1 9 9 8 ) . Tex tbook o n In terdiscipl i nary POlin M il n ageme n l . Ed i nburgh: C h u rc h i l l Jull,
L iv i n gsto n e .
McIndoe. R . ( 1 9 9 5 ) . Mov in g o u t o f p a i n :
h a n ds-on or h a n ds-o rr. In Movi n g i n
S hacklock. ed . ) 1 5 3- 1 60. O x fo rd : B u t terwor t h
on Pa i n ( M .D.
pp.
He inem an n .
Me n s . I . M . A . , V l e e m i n g . A . . Stoec kclf t . R . e t a l . ( 1 9 9 6 ) . U n d e rsta n d i n g pe r i pa r t u m pelv iC p a i n : i mp l i c a t i o n s of a p a t i e n t s ur vey. S p i n e . 2 1 . 1 3 h3-1 3 70. Mens. I . M . A . . V l eemin g . A . . Snij ders . c.J. et a l . ( 1 9 9 7 ) . A c ti ve s t ra i gh t l e g ra i S i n g test: a cl i n i c a l approach t o t h e l o ad t r a n s fer fu n c t i o n of the pe l v ic g i r d l e. I n M ove m e n t . S t a b i l i t y a nd L o w B a c k
( A . Vleel1l i n g. V. M o o n ey. T. Dorl1l a n el a l . . ed s . ) pp. 4 2 S-4 3 3 . Ed i n b urg h : C h u rc h i l l Li v i n g s t o n e . M e n s . I. 1vI . A . . V l eem i n g . A .. S n i j d crs. C . I . et a l . ( 1 9 9 9 ) . T h e a c t ive s t ra i g h t l e g r o i s i n g test o n cl mobi l i ty of t h e pel v i c j o i n t s . E u ro pe a n S pi n e l o u r n a l . S . Pa i n
4 6 8-4 7 3 .
I\1Ien s . I · M . A . . V l ee m i ng . 1\ . . S n i j d e r s . C . I . et a l . ( 2 0 0 ] ) . Va l i d i ty a n d reli a b i l ity of the active stra i g h t l e g r a i s e test i n pos te ri or pelv ic p a i n since p re g n a ncy. S p i ne, 2 6 . 1 1 h 7- J I n . Os tgaard, H.C . . A n dersson. C . R . I . a nd Ka r ls s o n . K . ( 1 9 9 ] ) . Pre v aJ e n ce of back pain in preg n a ncy. S p l n e . 1 6 . 549-5 5 2 . bs tga ard. H . c . . Zetherst r ii m . G . R .J. and Roos-Ha nsson . E. ( 1 9 9 4 ) . The posterior pe l v i c pain provocation test in pre g n a n t women. Europe a n S p i n e Jo u r n a l . 3 . 2 5 8-2 h O . Pool-Goudzwaard . A . L . . Vle e m i n g. A . . Stoeckart. R. et a l . ( l 9 9 8 ) . ins uffic ien t lu m bo pel v i c st a b i l i ty : a c l i n ica l . a n a to m ical a n d b i o mec ha n ica l a p pro a c ll t o ' a s p e c i fic' low back pain . M a n u a l Therapy. 3 . 1 2-20. Po tte r. N . A . an d Rothstei n , J. M . ( J 9 S S ) . In tertester reliability for selected c l i n ic a l tests o f the s a c ro i l ia c j o i n t . P hY S i c a l T h e ra py. h S . 1 6 7 1-1 6 7 5 .
R i c h ardso n . C . A . a n d Ju l l , G . A . ( 1 9 9 5 ) . M u s c l e c o n trol-p a i n c o n t ro l . What exe rc i s e wo u ld you p r e sc r i b e ? Ma n u a l Therapy. 1 . 2-1 0 . S c bop p i n k . L . E . M . . v a n T u l der. M . VV. . Koes. B . W. e t a l . ( 1 9 9 6 ) . Rel i a b i l i ty o n d va l i d i ty of t h e Dutc h adaptation o r the Quebec Rack Pa i n Disability Sca l e . P hy s i c a l T h e r a py. 7 6 , 2 6 8-2 7 5 . S h orla n d . S . ( 1 9 9 8 ) . Ma n <1 g e m e n t or c h ro n i c p a i n fo l l owing wh i p l ash inj uries . In To p i c a l Iss ues in Pai n 1 Whiplas b-Sc i e nce a n d M a nage m e n t .
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Feor-ovo i d a n c e B e l i e fs a n d Behi1v i o u r
ed . ) p p . 1 1 'i - I 3 4 . C N S Press. S t u ressn n . B .. Ud e n . A. and Vleem i n g. 1\. ( 2 0 00). f\ ra d i ostercomclric o n il ly s i s of moveme n t s o f the sacroi l i a c j o i n t s d u ri n g [ h e sta nclil rd h i p fl e x i o n test. S p i n e 2 5 . 1 64- 3 6 8 . S v e n sson. 1-l . O . . A n dersson . C . B.J . . H.ags t a d . A . e t a l . ( 1 ( 9 0 ) . The re l a ti o n s h i p o f low-back pa i n t o preg n a n cy a n d g y n ec o l o g i c ra ctors. Spine. 5 . 3 7 1 - 3 7 5 . v a n d e l' K l ooL W. A . . Onste n d o rp. R . t\ . R . . v a n J e l' M c i j . l . et a l . ( I ') ') ') ) . D e N e d c rl a n else vcrs i e va n ell' ( I... S . C i rrorcl .
l'a l !n o u t h . U K :
Mc C i l l l 'a i n O u e s t i o n n a i r e : cen
bct l'Ou w b a re v r i l gen l i j s t . Nederla ncls
(:cllecsk u nde. J 39. 6 6 9-(, 7 3 . v a n M c e tc r e n . I . , Mcns 1 . 1\11 . 1\ . cl n d S t a m . H . I . ( 1 9 9 7 ) . Rel i a b i l i t y o r st r e n gt h mea s u rement o f' t. h e h i p w i t h a h a n d - h e l d d y n a m ometer i n h e a l thy wome n . E u ro p ea n J o u r n a l of P hY S i c a l M e cl i c i n e and R e h a b i l i t a t i o n . ' I ' i j d sc h r i ft vonr
7 . 1 7-2 0.
v a n W i n ge rden . J. P , V lccm i n g .
A. . ( 1 9 9 5 ) . I n t eraction of s p i n e <I n d l e g s : i n n u c n c e of h o m s t ri ng tension on l u m bo-pe l v i c rhy t h m . In S t a m . H . J . et a l .
S eco n d i n terd iscipl i n a ry Wor l d
Co n g r es s o n Low B a c k Pa i n a n d i ts Relation to t.he S f J o i n t ( A . V l e c m i n g . V. M o o n e y. T. Dorm a n and C . I . S n ijders. ed s ) pp. 1 0 9- 1 2 3 . Rotterd a m lOCO. Villi W i n gcrci e n . I . P . V l e e m i n g , A .. K le i n re n s i n k G.I. ano S toe c k a r l . R. ( 1 9 9 7 ) . T h e role of t h e h a m stri ngs i n pe l v ic a n d s p i n a l fu n c t i o n . I n Move m e o t . Stab i l i t.y a n d L o w J3 a c k Pa i n ( A . V l ee m i n g. V. Moon ey. T. Dorm a n et. a l . . cds. ) pp. 2 0 7- 2 1 0 . Edi n b u rgh : Ch urch i l l L i v i n gsto n e .
V l aeyen. I . W. S . . Kole- S n i j d ers. Boere n .
A. M.I. . R . C . B . e t a l . ( 1 9 9 5 1 . Fcor of'
m ove men t/( re ) i nj u ry i n c h ro n ic l ow
back pa i n a n d its relotion to behav ioura l 6 2 . 3 h3-3 7 2 . V l aeyen . W.S . . [( o l e -S n ij d e r s . A . M . I . , Heu t s . P H . T. C . e t a l . ( 1 9 9 8 ) . B e h a v i o ra l a n a l y s i s . re a r of' m o ve me n t ( re ) i n j u ry a nd behavi ora l re h a b i l i ti1l.ion in c h r o n i c low b a c k performa nce. Pa i n .
p a i n . I n T h i rd I n t e rd i s c i pl i n a ry
Congress on Low Back a n d Pa i n ( A . V leem i n g . V. Moo ney, H. T i l s che r e t al . . eds . ) pp. 5 7-h9 . Rotterd a m : £CG.
Worl d Pe l v ic
2 1 C H RO N I C P E R I PART U M P E LV I C PA I N
Vlecm i n g . A . ( 1 9 9 8 ) . I n t rodu c t i o n . I n Th i rd I n te rd isci p l i nary World C o n g r es s on Low Back and Pel v i c Pa i n ( A . V l eem i ng. V. Moo ney. H. T i l s c h e r et 31 . eds . ) pp. i i i-iv. Ro tterci <l m : ECO. V l eem i ng. A . . Poo l - C o u d zwo il rd . A . L . . Stoec k a r t . R . e l a l . ( 1 9 9 3 ) . Tow a r d s a bette r u n d e r s t a n d i n g o[ t h c et iology of l o w b'lek pil i n . l n Fi rst I n t erd isci p l i n ;l ry World C o n g ress o n Low l \ ,,,' k Pa i n a n d i t s R e l " t i o n t o .
th e S I J O i n t ( A . Vleem i n g . V. Moon ey. H Til scher e t al eds.) pp. 5 4 S- 5 5 3 . Rotterd a m : ECO. V lee m i n g. A .. S n ijders. C.J . Stoec kart. R . e t 3 1 . ( 1 9 9 5 ) . A new l i g h t o n low back pa i n . I n Second I n terd iscip l i nary World Co n g ress o n Low Back Pain and i ts Relation to the S[ J o i n t ( A . Vleem i n g el a l . . eds . ) p p . 1 2 3 -1 3 1 . Rot terdam : ECO. Vlecm i n g . t\ Me n s . I. M.A de Vries. H. e t a l . ( 1 9 9 8 ) . Pos s i b l e role o f the . .
.
..
..
Copyrighted Material
En,
long d o r s a l sacroiliac l i gam e n t in per i p arlum pel v i c pa i n . I n Third Interdisc i p l i n ary Wor l d Con gress on Low Back a n d Pe l v ic Pa i n ( A . Vleeming. v. M o o n ey. H . T i l s cher et 31 eds . ) pp. 14 9 - 1 5 7 . Rotterdam: ECO. Wa dde l l . G. ( 1 9 9 8 ) . The B a c k Pa i.n Revo l u t i o n . Ed i nbu rgh : Ch urc h i l l ..
Liv i n gs t o n e .
C H A PT E R
Ac ute o n c h ro n i c l ow
22
bac k pai n Richard Walsh and Stanley Paris
�
S U BJ E C T I V E EXAM I NAT I O N
. Tony i s a 4 2 -ye a r-old male who works as a systems admin i s trator fo r a newspaper compa ny. He attended our c l i n i c compl a i n i n g of back p a i n . ' b ack spasms ' . a n d p a i n a nd t i n g l i n g i n to the left posterolateral mid-thigh
a n d t h e latera l p l a nta r aspect of
the
left foo t . D u r i n g the l a s t 3 m o n t h s he h a d no ted a grad u a l wo rse n i n g of h i s symptoms, with a decreas i ng a b i l ity to perform gym worko u ts and recre ati o n a l cyc ling a s
a
resu l t of t h e low back p a i n (LB P ) .
To ny h a d a l O -year h i s tory o f LBP w i t h no i n i t i a l precipitating incident. S e v e n years ago he a ttended approx i m a tely seven p hys i c a l therapy ses s i o n s , which he
reported
consisted
of heat,
e lectrotherapeu tic
moda lities and a ' gym-base d ' exercise programme, with minimal c h a n ge i n h i s symptoms. His other medical
history
i n cluded
fractu res
of
the
right
c l av i cle, fore a r m and l e ft j aw, none o f which occurred in
the
last
5
years .
and
a tri al
fibrillation
and
depression . One month prev iously To ny h a d been e v a l u a ted by or thopaedic and p hysical med icine physicians at a specialty spine centre.
The work-up i n c l u ded
magnetic reson ance ima g i n g (MRI) , b loodwork , nerve cond uction s tudies and a p hysical therapy assess me n t . The blood work and nerve cond u ction s tud ies were u n re m arkab l e . He was referred for physical ther apy a t our fac i l i ty with a d ia gnosis of ' s pondyl o lysis L S -S l , degen erative d isc disease L4-L 5 ' . The refer ring phy s i c i a n ( p hy siatrist) recommen ded t h e avo i d a n c e of exte n s i o n exercises .
F ig. 2 2 . 1
340
Copyrighted Material
Self-repo rted areas of p a i n .
2 2 AC U T E O N C H RO N I C L O W BAC K PA I N
( 1 9 9 5 ) . I t has demonstrated good rel i a b i l ity (test
Self- reporti ng fo rms A t our cl i nic. the standard i n take forms include a
body chart for p a i n . the McG i l l p a i n qu estio n n a ire
(MPQ) (Mel zack. 1 9 7 5 ) and the Roland Morris Disability Questio n n a ire ( Roland and Morris. 1 9 8 3 ) i n a mod i rLed form ( m RMDQ) ( Wa l s h . 1 9 9 9 ) . To ny marked his body chart ( F i g . 2 2 . 1 ) with crosses in the region o f the central l u m bar spine. left p o p l itea l fossa. a
n d the plantar a s p e c t o f the heel and first metatars a l
o n t h e l e ft side. He a l so i n d i c a ted pain rad iating fro m the lu mbar spine d o w n t h e posterior aspect of the left lower extremity. He rated his pain as 5 / 1 0 where 0 is no p a i n and 1 0 is excruciating p a i n . One week prior. whi le playing gol f'. h i s pain was 7-8 / 1 0 . T h e m RMDQ t hat was adm i n istered is based on
retest reliab i l ity a nd inter n a l conSistency) and sensi tivity to change
(Walsh . 1 9 9 9 ) . The i n it i a l mean
score on t h i s scale for patien ts attend i n g our clinic approximates 1 3 / 2 4 . This p a t i en t s mRMDQ score '
was comparatively high ( 2 0 / 2 4 ) . O n the MPQ he marked 1 8 i tems in eight categories . with six of the marked i tems i n categories 1 1 through 1 6 . Because o f To ny 's history o f depressi o n . a modified Zu n g De pression Index (ZDI) was also a d m i n istered (Main and Waddel l. 1 9 8 4; Zung. 1 9 6 5 ) . The screen ing cut-off for depression with this tool has been reported as 3 3 / 6 9 . the hig her the score the greater the d epress i on. This patient scored 5 3 / 6 9 . an extremely
h igh score.
the form atting and word ing pro posed by Patrick et al.
� I }
-
II
REASO N I N G D I S C U S S I O N A N D C L I N I CAL REAS O N I N G C O M M E N TA RY
C o u l d you i d entify any potential patte rns i n
ram ifi cations d i d the fi n d i ngs have fo r yo u r
To ny's p res e n tation a t th i s early s tage? What
ma nagement a n d p rogn os i s ?
fi n d i ngs p rom pted you r tho ughts i n this rega rd ?
• C l i n i cians'
• C l i n ic ians' an swe r
an swe r
It appeared that the symptoms were a res u l t of l u m b a r s p i n e pathology. A t this stage, there w a s nothing defi nitive to indicate pathology of one particular l u m bar tissue over another ( for exa mple. disc versu s facet joint versus l igament) . This is hardly surprising because the majority of the time it is not possible to identify
a
specific tissue as the cause of LBP (Deyo
et al . . 1 9 9 2 ) . The pain radiating below the knee may be indicative of a discogen i c problem with neural tiss ue comprom ise. However. because m uscles. l i gaments and the facet j o i n ts are capable of producing pain a simil ar distribution (Inman and Saunders . 1 9 44: Kel l g ren . 1 9 3 8 : Moo n ey and Robe rtso n . 1 9 7 6 ) it is
\vith
best to avoid j u mping to h asty concl usions. particu l arly this early in the eval uatio n . Nonetheless . the provided radiologica l fmd ing of a spondyl o lysis (L5-S l ) meant that conti n u ed consideratio n o f impairme n t ( for ex a m p le hypermob il ity or hypo mobil ity) at this .
level was warra nted .
EJ
Roland and Morris ( 1 9 8 3 ) suggested patients with scores of 1 4 or greater ( when using the original scale) on the disabi l i ty questionnaire are more likely to h ave a poor o u tcome. It was. t herefore. an tiCipated that this wo uld be a potentially chal lenging case. For the MPQ. it has been s u ggested t h at category scores grea ter than 1 6 . or the marking of i tems i n categories 1 1 through 1 6 . may represent severe or excess ive emotio nal reac tion to pain (Paris . 1 9 8 0) . On th at basis. Tony 's pain questionna ire indicated heightened emotional overlay. Patients w i th LBP whose ZDI scores are g reater than 3 3 / 6 9 h ave been categorized as 'depressed d istressed ' in the distress and risk assess ment model (Main et al . . 1 9 9 2 ) . These patients are th ree to ('o u r times more likely t o h ave a p o o r outcome compared with those who score less than 1 7 / 6 9 (classified as norma l) on the ZDI. Because depress ion is a key indi cator [or poor outcome i n patients w i t h LBP (Bu rto n et a l . . 1 9 9 5 ) , To ny was enco uraged t o follow-up with the medical professional who was overseeing this aspect of his hea l th care. Following this recommend a
What was yo u r i n terpretati o n of the res u l ts of
tion Tony arra n ged to see his psyc hiatrist. with the
the q u e sti o n n a i re s ? In parti c u l a r, what
referrin g p hysici an informed of these developments.
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C L I N I C AL R EASO N I N G I N ACTI O N : C A S E STU D I ES F RO M E X P E RT M A N UAL T H E RAPI STS
The b e n e fi ts of a h o l i s tic appro a c h to the trea t m e n t of LBP were emph asized to Tony a nd h e was ag reeable to a l e r t i n g the psyc h i atrist to his
LBP
It was p l a n ned to track t h e 2m scores as To ny pro g ressed t hro u g h treatme n t . We hy pothesized that a decrease i n the depress ion score wo u l d correspond w i t h a n i mprove m e n t in Tony's LBP a nd a red uction in h i s mRMDQ score. A s we w i l l l a ter e l aborate , we ty p ic a l ly present the fi nd i n gs from th ese q uestion n a i res to the p a tient o n completion of the eva l u a ti o n a n d t h i s serves as p ar t o f t he e d u c a t i o n process reg a rd i n g the emotio n a l compon e n t o f t h e i r p a i n presen tation
and
the
p a t i e n t ' s fu n c ti o n a l
sta tus.
However, i n i nstances such as here. when t h e scores are p a r ticu l arly e l eva ted , we spend extra ti me w i t h the p a t i e n t ex pl a i n i n g the phy s i c a l rea sons for t h e i r p a i n . W e fee l t h i s h e l ps the p a t i e n t t o r a t i o n a lize the i r problem a n d , t h e re fore, pote n ti a l ly reduces the e m o tio n a l compone n t o f the i r prese n t a t i o n .
It h a s b e e n
o u r expe r i e n ce t h a t cou nsell i n g t h e patie n t i n this m a n ner can b r i n g ab o u t an irruned i a te reduc t i o n in a patient's
MPQ score. F u r thermore, s e l f-reporti n g
question n a i res m ay later serve as u s e fu l a dj u nc t s to the p hysical fi n d i n g s a nd fu nction a l go a l s in demon stra t i n g i m provi n g s t a t u s o f the pati e n t .
• C l i n i c al
be u n u s u a l i f they h ad n o t . Research h as d e m o n strated t h a t expert man u a l t h e rapists norm a l ly generate hy pot heses from the o u tset of the c l i n i c a l en co u n ter ( R ivett a n d Higgs. J 9 9 7) , These i n i t i a l hypot heses a re n o t accepted u n til they h ave bee n adeq u a tely tested w i t h d a t a from fur ther e x a m i n a tion . p a r t icu l a r l y i n c a ses s u c h several p a t h o l ogies
are
as
t h is where
capable of produ c i n g s i m i
l a r p a tterns of sy mptoms, To do otherw ise would i nv i te errors i n c l i n ic a l reaso n i ng res u l t i n g from b i a sed t b i n k i n g and i n complete
dat a c o l l ec t i o n .
M a n u a l therapi sts t oday a r e req u i red t o b e m u l t i faceted i n their c l i nical reason i n g i n order to ensure they offer an effec t ive and holistic approach to man agement . In this case, i l l addition to con S ideri n g physical impa irment.s, long t h e traditi o n a l domain of manual t hera p i s t s . t h e exper t clinicians h ave iden t i fied an i mpor t a n t need to consider psych oso c i a l impairmen ts (e.g, depression ) . It is clear that
tbey
con sider
t hat
dysfu nctional/impaired
and
counterprodu ctive beliefs a ncl fee l i n gs must Ilrst be addressed through education and rea ssu ra nce so as to e n.h a nce the like l i hood o f a favou rable out.come, It is of i n terest to note t h a t the i n formation ob t a i ned
reaso n i n g co m mentary
from t.he q uestio n n aires
i n form c l i n i ca l reaso n i n g in
a
has bee n u sed to
n u mber of hypo t hesis
Despite the note of c a u tion about ' j u m p i n g to
c ategories , i nclud i n g act i v i ty/parti cipation rest ric
h a s ty conclusi o n s ' , it i s appare n t the c l i n icians
tions, p hysical and psychosoc i a l i mpa irmen t s . man
h ave recogn ized early cues and fo r m ed some tenta
agement and prognosis, This makes the time spent o n
tive d i a g n ostic hypotheses ( e , g . d i scoge n i c problem
thei r admin istra t i on and i n t erpretation wel l j u stifled ,
Patient i n t e rview
-
"
_
It
w i t h n e u r a l t i ssue compro m i se ) . I ndeed , it wo u l d
.H
_
1
:�
���
n i g h t . Moreover, whenever he fel l asleep on h i s stom ach his back and leg sympto ms worsened and h is s leep
is o fte n h el p fu l to question a patient a bo u t the p re
was fu rther d isrupted by the pain. If he did not sleep on
cise l oc a t i o n of t he o n set of their p a i n because t h is
h i s stom a c h , he reported awaki ng in the mor n i n g with
site c a n help to i nd i c a te t h e pos s i b l e s o u rc e of the
less LBP a nd leg p a i n tha n at any other time of the d ay,
p ai n . In response to the q u e s t i o n , ' P recisely where d id
The 2 4 hou r pain p attern was one of gradual deterio
yo u r p a i n begi n ? ' , To ny reported three site s : both pos
ration thro ughout the d ay, whic h appe ared to be
terior su peri o r i l i a c s p i n es and the l a tera l aspect of
related to the amount o f time he was up. Apart from
the l e ft t h i g h . a t the j u nction o f the prox i m a l two
resti n g i n a s u pine-ly i n g position. Tony was not aware
t h irds o f the thigh and the d i s t a l t h i rd of the t h i g h .
o f anything that red uced his symptoms. He had not
S u bsequently, h e a l s o n o ted tin g l i n g an d n u mb ness
self-admi n istered ice or heat a n d he had not filled a pre
o n the l a tera l a s pect o f the left fo ot.
scription for ce lecox i b ( a n ti-in l1amma tory medication )
When q uestioned about his prese nt sleeping pat
provided by the refe r ring phYSician . He verb a l ized a dis
tern . Tony vo lunteered that his life was in a period of
like o f med ications as the basis for his non-comp l i a nce.
turmo i l , primari ly through domestic confl ict. and that
His primary goa l was
this was red u c i n g his s l eep to o n ly 3-4 hours each
' wori<Ln g out at the gy m and cycl i ng ' .
Copyrighted Material
a
return to fu n c tio n , speci llcally
2 2 AC U T E ON C H RO N I C LOW BAC K PA I N
The p a t ient d e n i e d any altered sen sation , pai n or D u m bness i n the 'saddJ e ' d istrib u tion , and a ny c h a n ges
experienced a ny recen t changes i n body temperatu re or body weigh t.
in bowe l or bladder fu nction, The pat i e n t h a d a l so not
R E A S ONING DISC U S SION AND CLINICA L R E A S ONING COMM E NTA RY
D
Did you directly or indirectly ascer ta i n Tony's understanding of his condition and management to date?
• C l i n i c ians' an swer From the information gleaned thus far in the e valu ation . we be l i eved that to some degree t h i s patient's
• C l i n i c ians' answer
symptoms e m anated from mecha n ical compromise
U p to this poi n t , Tony had n ot u nder take n any i n de
Mech anical and inf1 ammatory nociceptive in put from
of
peri phera l somatic and/or neurogeni c tissues.
pe n d e n t ex ercise prog ramme o r se l f-ma n a geme n t for
a variety of l u mbar tissues was s u spected. In support
h i s LBP. In our experience, some patien ts pre fe r to b e
of this was the finding t h at Tony's symptoms were
t h e reci p i e n ts o f passive care rather t h a n being active partici p a nts
in
th ei r
rehabilitat i on.
Pe rhaps
this
patie n t had not been afforded an opp or t u n i ty to b e act i vely involved i n add ress ing h i s LBP or, a l terna t i ve ly, he h a d decl i ned to do so, We bel ieve t h a t a ll L B P
relieved in certain positions ( s upine lying) and made worse in other positions ( prone lyin g ) . At this stage it
wa s felt that a spondylolysis with accompanying instabiJ ity could b e responsibl e for such a pain presentation. Give n Tony's long history of
LBP it was conceiva ble
patien ts must be active par tic i pants i n the ir care i f
t h at there w a s al so a ce n tral mechan i s m c on tributi n g
recovery is to prog ress opt i m a l ly. I n itially i t was fe l t
t o the pai n . The ch ronic n a tu re o f t h e co n d i tion
that this patient
had come t o physical therapy t o b e
pa s s i ve l y ' [l xed' ,
wou ld se nsiti z e the c e n t r a l nervous system ( C NS ) a nd the periphera l n o ciceptors . relatively reduci n g Tony's
Consequently, it was expected that the i mportance
pain t hres h old. th us prol on g i n g and a mplify i n g the
of acce pt i n g an active role in the treatme n t pro
pain. This c han ge in s e n s i t i vi ty of t he
gra m me wou l d need to be e m p h asized to Tony. He
times re fe rred to as ' wind-up' .
CNS is some
d e mons trated some deg ree of u nd e r s tan di ng of h i s
T h e third and pos s i b ly most important mecha nism
diagnosis b u t was unclear as t o why he was n o t a s u r
c o n tr i b u ting to t his patient's pai n presentation was
g i c a l c a ndidate for rect i fication of the spondy l ol ysis at
the psychosocial i mpairmen t . The history of depres
this time . We h ave fou n d t h at many pati e n ts atte n d
sion . the resul ts of the self-reportin g m e a s u res a n d
i ng ou r cl inic for their fi rst visit frequ e n tly requ ire
the di scord present i n h i s h ome s e t t i n g suggested a n
fu rther e d u c ation regarding
a ffective pain mechan ism was present and respon
their problem.
This
par ticu l ar pat i e n t was by no means i g norant of his d i agnosis but it was felt t h a t he .
clear expl anati o n of his diagn os is. his problem list and the proj ected p lan of care. followi n g the comple tion of his evaluati on .
II
• C l i n i cal The
reaso n i n g co m m entary
c l inici a n s
are clearly attempti ng to gain an
as a p e rs on that is the context of his p r o bl em This incl udes both the pat i en t s perspective of the p rob le m ( e . g . j ust a pass ive ' fix ' is n eeded) a n d factors poten tially co n tributing t o the maintenance of the problem (e.g. s tressfu l home situatio n ) . This r e qu i r es a c l i n ical reasoning strategy, referred to as narra tive re a s o n i n g (see Ch . 1 ) . The grea ter i n s i g h t a fforde d by narrative re ason i n g is required to u nderstand the u nderst a n d i n g of t he patient
Given Ton y 's long h i stor y and apparent
.
.
psychosocial i m pairment, did you at this
'
stage think that h i s sym ptoms were
dominantl y nocicept i ve ( i . e . emanating from peripheral somatic and/or neurogenic tissues) or did you hypothesize a central pain
mechanism ( i .e. altered processing or sensitivity of the central nervous system) as a further possi bility ?
s i b l e for some of Tony ' s p a i n .
w ou ld be nefi t from a
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C L I N I C A L REASO N I N G I N ACT I O N : CASE STU D I ES F RO M E X P E RT M A N UAL T H E RA P I STS
patient and effectively interact with them to fac ilit ate
c a r e ) . and fosteri ng t h e pati e n t ' s i n s i g h t i n t o t h e i r
c h a n ge i n their be h avio ur, su c h as active p a rticipa
o w n beliefs . feelings a n d behaviours. Consequen tly,
tion i n their m a n a geme n t . Dysfu n ction a l / i mp a i red
effect ive
cU1 d coun terprod uctive ( to recovery) behaviours can
persona l and i n q u i ry ski l l s , releva n t kn owledge, a n d
n a rr a t ive
reaso n i n g requires sound i n ter
often be positively addressed through edu c a ti on , as
manageme n t strategies a n d referral pa thways to
i l l u s tra ted i n th is case (e.g. a clear explanation o r his
other h e a l t h profession a l s . partic u l a rly in the field o f
diagnos i s , his p r obl e m l is t a n d the p roj ected plan of
mental hea l t h .
tE P H YS I C A L EXA M I N AT I O N Increased thorac ic ky phosis and l u m b a r lordosis were
of t he posterior s uper ior i l i a c spines t o
noted on e x a m i nation (Tony i s an ectomorphic Cau
superiorly
casia n ) . In standing, there also ap peared to be increased
between th e two points with lu mbar ex te nsi on and the
tone in the mid - l u mbar parasp i n a l mus c l es i n
a
ness or ' s tep ' i n t he l u mb ar i n te r spi no u s space s . When
m a tely
a
' step ' may be
tic, a nd at the level above i f it is isthmic ( lytic, elong ated but i n tac t pars i n terarticu laris , or trau matic) (Fig.
2 2 . 2 ) . This d i ffe re nce occurs beca use i n the isth
mic s tates the posterior e leme n ts do not s l ip forwa rd Active range o f m otion was reco rded using the
the
a
p o i n t I S cm
approx i mation
moti o n s . A l l movements ap pea red to oecur p rimar i ly i n the mid-lumbar spi ne in a fu lc ru m-like man ner. Neu rological assessme n t revea led normal streng th, rell exes
( Weinstei n, 1 9 9 5 ) .
noting
lu mbar flex i o n . Flex i o n was + 2 em ( approx i 3 0 % of normal r a n ge) and ex tensio n was w i t h i n n orma l l imits ( - 2 cm) . Side be n ding was esti mated as 5 0% o f norma l ran ge to the right and 7 5 % of norm al range to the left . with LBP li mit i ng both
with
a pp a ren t a t that l eve l if it is degenerative or dysp l as
then
amo u n t of s k i n d i s traction between the two pO i n ts
· b a nd ' . Palpation d id not reve a l a ny obvi ou s tender pat ie n ts have a spondylolis thesi s ,
and
a nd
l ig h t touch sensation
i n the lower
ex trem ities . Stra i g h t leg raise (SLR) was SO d eg rees
modified - mod i fied S c h o ber method ( Wi ll i a m s et a i . ,
on the left and 60 d e g rees on l h e righ t w i t h a muscle
1 9 9 3 ) . This method involves measuri n g fro m the level
end -feel a n d Tony reported feeli n g a s tretch in e a c h
L4-L5 step-df i s above the level of s l i p
L4-L5 step-df i s below the level of slip level o f s l i p
L5-S 1 level of slip
F i g. 2 2 . 2 Fractu re spondylolisthesis (a) can be d iffere ntiated from degenerative spondyl olisthesis (b) by the 'spinous process sign'. I n the fo rmer, the fo rwa rd s l i ppage of the anterior portion of the ve rtebra creates a pal pable step-off of the spinous processes at the interspace above the level of th e s l i p. I n the latter, the i n tact verte bra s l i ps forward as a unit, creating a step-off at the interspace below th e level of th e s l i p. ( F rom McKinnis, 1 99 6 , p. 1 98 as adapted from G reenspan, 1 99 2 , p. 1 0- 42. Reprod uced with kind permission of the publishers.)
Copyrighted Material
2 2 A C U T E O N C H RO N I C LOW BAC K PA I N
'if'
h a mstring. The addition of passive d orsiflexion at the
from 2 / 6 to 2 + / 6 ; Go ne ll a et a l . , 1 9 8 2 ) . A s l u m p test
a n kl e d id not c h a n ge the patient's report. Femora l
was then performed as descri bed by Bu tler ( 1 9 9 1 ) , w h i c h demons trated a l i mitation i n knee extension of
nerve tension testing was u nrema rkable. Examination of the sacroiliac joints using pain
1 5 degrees o n the right and 10 degrees o n t h e l e ft ,
provocation tests (compression and gapping) was
w i t h Tony repor ting a stretch fee l i n g i n each h a m
asymptomatic. A battery of tests were used to examine
string b u t no reproduction o f sympto m s . This limita
the h i ps including passive motion testing, the FABER
tion was considered u n remarkable.
test. the scour test and Trendelenburg's test, aU of which
Beca use of t he elevated MPQ score and the possi
were unremarkable. The sign of the buttock test was
bility o f non-orga n ic pain, tests for Waddell ' s signs
performed with Tony in supine lyi n g and was nonna! .
were performed ( Wad d e l l et a1 . , 1 9 7 9 ) . These tests
During this procedure, the clinician raises the patient's
are used to identify i f there are what Waddell terms
leg with the knee extended u n til the motion is lirruted or
' be h avioura l signs' (Waddell. 1 9 9 8 : see Ch. 5 for a
pa inful, which equates to
SLR test. At that point the
description a n d assessment of the sign i ficance o f
lmee is Ilexed and further hip Jle>.ion is attempted . r r the
these signs i n manual therapy ) . A posi tive response i s
patient tolerates continued hip movement then neither
occurrence of L B P with very m i ld a x i a l l o a d i n g o f the
the hip nor the struclu res spanning the hip alone are
spine, simu l a ted trunk rotation or s upertk i a l skin
a
likely to be responsible for the initial limitation. If, how
roll i n g at the lumbar spi ne. Other Waddell signs are a
ever. the patient c annot tolerate fur ther movement then
marked difference in SLR i n sitting versus supine
the hip may be implicated . Magee ( 1 9 9 2 ) suggests that
lyi n g , sensory c h a n ge beyo nd the normal innerva
a positive test may i ndicate serious hip pathology in the
tion tleld and d ermatome d istribu tion ( fo r example,
form of osteomyelitis or sacral fractu re.
decreased light touch sensa tion in a 'stockin g ' distri bution) and n o n-myotomal motor wea k ness ( for
Muscl e l e n g t h tests [or the psoas a nd rectus femoris muscles (Thomas test) , as well as Ober's test
example, weakness o f the enti re lower extremity).
for the length of t he ilioti b i a l band, were within nor
These tests were unremarkable (0/5 where a score of
mal l i rruts b i l a teral ly.
3 / 5 or g re a ter i s suggestive o f non-orga nic p a in ) .
When Tony was positioned i n prone lying, the l u m
A t this time t h e diagnostic imaging tllms were
b a r paras pinal muscle activity was less noticeable a n d
reviewed a n d the L5-S 1 spondylolysis was contl rmed ,
again no 'step' was palpable. Passive physiological inter
w i th the M RI a lso i n d icati n g the presence of a grade r
ver tebral movement ( PPrvNI) testing of the lumbar
spondyloli sthesis at this level.
spine revea l ed d i ffuse, slig h t hypomo b i l i ty (rangi n g
m D
REA SONING DIS C U S S ION
j O i n t and soft tissue ( hamstri ng) hypomobility, with a
What was your impression of Tony's presentation at the concl u sion of the phYSical
heighte ned emotional component. L u m b a r instabi l
examination ? Did you consid er the finding of a
i t y w a s hypothesized a s t h e u nderlying cause of the muscular g u ardi n g and consequent spinal hypomo
spo n d ylolisthesis of clinical s ignificance?
b i l i ty. Ideally, passive motion testing i nvolves the clin ician undertaking test i n g with the patient en tire ly
• C l i n i c ians' answe r
relaxed . However, when the patie n t ' s resting m u scle
T h e res u lts of t h e physica l exa m i n a ti o n suggested
tone is higher than normal. for whatever reason ( fo r
that Tony was demonstrating clinical signs of phys
example, muscle guard i n g because of pain) , t h i s may
ical impairment a nd patho logy as well as being
res u l t in d ecreased passive j O i n t mobility despite the
depressed . Importan tly, the examin ation d i d not
fact that the tested j o i n t ( s ) m ay actually be hy permo
reveal a ny stro n g evidence o f ' red nags' [or neurolog
bile. The hypothesis of lumbar i nstability was based
ical compromise or systemic d isease. The i mpression
on the ' b an d i n g ' of muscle noted i n the mid- l u mbar
of Tony's presentation at t his s tage was of lumba r
spine, the worsening o f symptoms as the d ay progressed
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C L I N I C A L R EAS O N I N G I N ACTI O N : C A S E STU D I E S F RO M E X P E RT M A N UA L T H E RA P I STS
( Pari s . 1 9 8 5 ) . c a used by i n creasing tissue cree p . a n d
a n d a n g u l a ti o n . T h i s is d es p i te the fact t b a t o u r s p i n es
the fact t h a t ly i n g o n his s t o m ach aggravated the
do not typically fu nction in s u c h ex tremes of motion
symptoms . The fmding of a spondylolisthesis on imaging
( Pa r i s , 1 9 8 5 ) .
was a l so supportive as it c a n pote n ti a l ly cause spi n a l
I t i s poss i b l e t h a t a n i n d iv i d u a l w i thout a spondy lolisthesis c o u l d present i n a s i m i l a r fa shion to this
instabili ty. Insta bil i ty has been dell ned primarily by the deg ree
p a t i e n t . Conversely. one might argue that a n o ther
of vertebral translation or a n g u l a t i o n seen on rad io
individu a l with grade I spondy l o l isthesis could be
no abso lute va lue. figures have been s uggested for the l u mbar spine of greater than 4 . 5 mm s a g i t t a l p l a n e d ispl acement or 2 2 deg rees rel
e n t i rely asymptomatic. Therefore. it is more usefu l to
g raphs . Wh ile there is
reference
a
combination o r signs a n d symptoms when
m a k i n g a j udgment of i n s t ab i l i ty, as a s i ngle defi n i tive
ative s a g i tt a l plane a n g u lation between segme n ts
meas u re conti n ues to be e l u s i ve at th i s time . Whi le
( W h i te et a\ . . 1 9 9 9 ) . It wo u l d h ave been d es irable to
ack nowledg i n g these s h o r tcomi n g s , we feel j u stified
h ave had Oexio n-ex tensi o n fi l m s of t h is pa tien t to
i n prov i s i o n a l ly d i a g n o s i n g To ny as having ' c l i n i c a l
help to dete r m i n e t he a m o u n t of vertebral tra n s l a t ion
i n stabil i ty ' of t h e lu mbar s p i n e .
B;WrfB§;.t'" -
• Visit 2
At the end of the assess ment, the fi n d i n g s and work
etine for h is depression .
. Visit
1
ing hy pothesis were exp l a i ned to Tony with the use of a mode l of the s p i n e . A posi tive prog nosis was con veyed to Tony, w i t h eight to ten treatment sessions proj ected before disch arge o n a home and gym based exerc ise prog ra mme. Par t of our clinical approach ofte n entails postpon ing treatment u n til the patient's second visit. This is because the evaluation slresses a variety of tissues and has the pote n tia l to aggravate the patient's condition . Therefore Tony
was
warned
of
the
possibility
of
increased discomfort following the evaluation . Noth ing further was under taken on the first visit apart from edu cation and advice about using ice a t home [or analgesic and cm li-inflarnmatory purposes. Because To ny a lways felt i mprovement in his symptoms fo llowi ng periods of rest, he was encouraged to rest several times per day in the recu mbent semi-Fowler position to facilitate d isc nu trition. The ration ale for this is the fact that the majority of disc rehydration occurs during the first hour of rest. He was also encouraged to avo id sleepin g in prone lying as his symptoms appeared to be better when he did not sleep in this positio n . We have found that advising patients to s leep with a pi llow between their
To ny repor ted no c h a n ge i n h i s symptom s . He had consulted w i th his psyc h i atrist who prescribed pa rox The firs t actual tre atme n t occ u r red at the second v i s i t . Tran sversus abd o m i n i s
(TA ) spi ne s t a b i l ization
exercises were i n i ti a ted with Tony i n supine lying Uull and R ic h ard s o n , 1 9 9 4 ) . TA con tractions were he ld for 1 0 seco nds for ten repet i ti o n s . This exercise was prescribed for the home setti ng and was to be per fo r m ed five t i mes per d ay. S i ngle k nee Il exion exerci ses
( 3 0 seco nds) and double k nee flexion exercises ( 6 0 second s) were a lso performed tw ice. These flexion exercises were to be c a r r ied out three ti mes d a i ly as a home exercise. Elec t r i c a l stimu lation a n d heat were a lso a d m i n i s tered [o r a n a lges ic p u rposes . A b ack school education video was v iewed that out
lined the basics of spinal anatomy and the performance of so u n d body mechanics throu ghout the day. A call wa s also placed to the psyc hiatrist concer ning Tony 's high ZDI score and specifically h i s 'some or l ittle of the ti m e ' response to the question 'Do you fee l others wo u Id be better off if you were dead ? ' . The purpose of this call was to alert the psychi atrist to what may be considered a ' red-nag' response in the depression i n dex. The psych iatrist appreciated this input and the c a l l helped to facil itate a team approach to Tony 's health care.
legs, in addition to taping a bottle cap to their sternum, to be q u i te useful in disco u ragin g them from sleeping o n t h e i r stomachs. FollOwing t h e eval uation Tony was also
• Visit 3
advised to in i tiate his celecoxi b prescri ption as directed
To ny reported no d i ffic u l ties with the exercises and he
by the referring physician .
was no lon ger h a v i n g leg symptom s . However, si nce
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22 AC U T E O N C H RO N I C LOW BAC K PAI N
the l a s t v i s i t To ny h a d worked Cl I I weekend in the yard
a b n o r m al i ty was d e tected w i t h pa l p a t i o n o f the t h o r
a nd now compl Cl i ned o f ' I ow back m us c l e s o ren ess '
acic s p i n e . PPIV I'vI assessme n t reve a l ed hy p o m o b i l ity
and left-sided su peromed i a l s c ap u l a p a i n . He a l so
on ri g h t rota t i o n a t 1' 3 -1'4 ( g raded a s 2 / 6 ) . Pos
repo r ted c o n t i n ued non-c o m p l i a nce w i th t a k i n g h i s
tero a n terior
med i c a t i o n s . H e was aga i n a d v i sed t o i n iti ate these
the a n teriorly rad i a t i n g pa i n .
med i c a t i o n s . It was expl a i ned to him that \1is lack of
Tracti o n o f the t h oracic
s leep a nd pers istent pain mClY both r Cl p i d ly i m prove upon i n i ti a ting the med i c a t i o n s a n d that there was no
accessory movem e n t 0 1' l' 3 reprod uced spine i n s u p i n e l y i n g u s i ng
a belt ( M u l l i ga n . 1 9 9 2 ) d ecreased the symptoms a n d . therefore. t h i s tec h n i q u e w a s perfo rmed fo r several
real concern w i t h addict i o n deve l o p i n g fro m ta k i n g
m i n u te s . Postero a n te r i o r accessory movemen t of T 3
these med ication s . I t was a l so pointed o u t t o To ny
w a s t h e n l'au n d t o be asympto m atic b u t t h e hy pomo
that there was some rece n t e v i dence to support the
b i l i ty with right rotati o n pers i s ted . T h i s was l'a l l owed
use o f a n t i d epress a n ts even in n o n -d epressed p a t i e n ts
by
with LBP (Hampton A tkinson et a I . , 1 9 9 8 ) . Theo ret
1' 3 -'1'4 seg m e n t . progres s i n g from m id-ra n ge i n i t i a l ly
he lp to address severa l o f
to the end of a va i l able range by t h e fi n a l osci l l a ti o n
p a i n mec h Cl n isms ( i n nanmlatory
(PariS a n d L o u b e r t . 1 9 9 0 ) . The p a t i e n t was i n s t r u cted
ica l ly, these medications wo u l d t h e hypothesized
a
set
of 10 osc i l latio ns into rig h t rota t i o n at the
nociceptive pa i n . i ncreased centra l nervous system
to ice the t h o racic s p i n e re g i o n [or 1 2-1 5 m i n u tes fol
sensitivity a nd the a ffective con tribution ) . so pers u ad
l ow i n g his home exercise prog ramm e . A l tho u g h the
i n g Tony to take his medication was of re a l importance.
thoracic spine pain appea red to be mecha n i c a l . Tony
Treatment for t h i s session i nvol ved advanc i n g the spine stabi l ization exerc ises to i ncl u de raisi ng the
leg
was advi sed to see a p hysiCia n if the pa i n
worsened
because i t had not been med i c a l ly eval u a ted and the
[rom the bed w i th t h e k nee nexed u ntil the thigh
thoracic dysfu nc t i o n had n o w been a d d ressed . The
approx imated the ver tical posi tion , while s i m u ltan
TA exercise was a l so a d v a nced to incl ude a l ter n a te l e g
eou s ly con tract i n g
the TA as prev io usly
i n s tructed . Ten
slides
i n the s u p i ne - ly i n g p o s i ti o n : h o wever arm ra i ses
repetitions were performed on each side with m a i nten
in fo u r-po i n t knee l i ng had to be te m p o r a r i ly ceased
a nce of good control thro u g h o u t . Two fu rther stab i l i
bec a u se o f the thoracic spine p a i n .
z a ti on exerc i ses were added : Cl i lern ate ra isi n g of each arm
while in the four- poi n t knee l in g position ( m a i n
To ny reported t h a t he h a d been
performing t h e
progress ive re l a x a t i o n exerc ises , albeit rather i n ter
a l o w grade TA contraction.
mi ttently. a n d they appe a red to be hel p i ng w i t h slress
2 0 repeti tions) a n d alternate raising of tbe knee [rom
redu c t i o n . He was enco ura ged to c o n t i n u e to perfo r m
taining
a
neutra I spine a n d
tbe ground wben s i m i l a rly positioned ( 1 0 repetitio ns).
the a c t i v i ty o n a d a i ly b a s i s a n d at t i mes of h e i g h t
The patient was
ened a n x i e ty.
a lso i n s tructed i n h a mstring s tretc h es
fo r both l egs. These were to be performed at home lw ice
daily for two re petitions and sustained for 6 0 seconds to in crease the muscle length ( B a n dy et a 1 . . 1 9 9 7) . In
• Visit 5
additio n , to help to cou nter the 'domestic stress' Tony
Five d ays l ater To ny repor ted t h e LBP c o n t i nued to
was experien c i n g , he was instructed
in d i a phragm atic breathing i n c on j u nction with prog ressive relax a tion
dimi n i s h , with t h e resti n g p a i n now 3 / 1 0 ver s u s
exercises (Jacobsen . 1 9 3 8 ) .
p a i o c o n t i nued to persist a l t h o u g h i t was less i n tense.
A t this time i t was decided n o t to treat the tb oracic p a i n as th i s was not the pri m ary reason fo r t h e i n itial referra l a n d i t was fel t that t h i s p a i n
was
prob a bly the
5 / 1 0 o n t h e i n it i a l eval u a t i o n . However, the thoracic T h e 1' 3 -1'4 i n tervertebral j oi n ts
pulsed u l trasound
were tre a te d with
for 5 m i n u te s . The spinal stabi l iza
tion exercises were prog ressed with the a d d i t i o n of leg
mRMDQ
resu l t of wor k i n g i n the yard and wo uld s u bside w i th
exte n s i o n i n prone lying. The
time.
were administered a ga i n . The score for the
a n d tbe ZOI
mRl'vlDQ
was 5 / 2 4 and the ZDI score was 3 9 / 6 9 , both i n d icat
• Visit 4
i n g substa n t i a l progress s i n c e the eval u a tion. This
Tony was now bei n g seen for the second week a n d he
i l l u s tr a t i o n of his prog ress . The i m proved scores may
was ex p l ained to Tony who was
reported that he h ad i n i t iated his med icatio n s . The thoracic pain was now the primary c o m p l a i n t a n d i t rad iated a ro u n d to the a n terior chest. N o pos i tio n a l
h ave been a
delighted with th is
resul t of our i n terven tion s , as well as pain-relieving a nd beneficial psyc h o logical effects of the med ication s . It is likely that improvements fro m the
Copyrighted Material
C L I N I C A L R EASO N I N G I N ACT I O N : C AS E STU D I E S F RO M E X P E RT MAN UAL T H E R A P I STS
�
I
I .I
-,,' F ig. 22.3
----- . -
�'I '
/ '---'-'"
1 9 9 2 ) . T hose w h o have ZO I scores b e lwee n 1 7 / 6 9 a nd 3 3 / 6 9 a nd record less than 1 2 on the MSPQ h a ve --� .
twice the l ikeli hood of
a
poor outcome. Consequent ly,
we felt t h a t this patient was sti l l at risk. Treatment con
,
tinued with progression of the TA exercise to s t a n d ing
l�.)
( 1 0 repetitions w i th contraction held for 10 second s ) , a s well as th e a d d i t i on o f gen tle card i ovascu lar exer
Lumbar sta b i l i zati o n exerc i s e in the fo u r- p o i n t
k n e e l i ng p o s i ti o n , s i m u l ta n e o u s l y ra i s i n g t h e o p p o s i te a r m and l eg. ( F r o m Pa r i s , 1 9 97, p. 22, Reproduced w i th kind p e r m i s s i o n of th e p u b l i s h e r.)
cise fo r 5 m i n u t es and knee exte n s ion ( 5 0 repeti tions) a nd heel raise ( 4 0 repetitions) gym exercises . Arm raises i n fo u r-po i n t kn e e l i ng were a ls o r e c o mm e n ce d .
• Visit 8 in b o t h p hy s i c a l and p s yc h o l o gi c al st a tu s c o m b i n e d t o p r o d u ce the c h a n ges i n these measures.
To n y ' s home exercises were reviewed. To add ress Ton y 's goa l of retu r n i n g t o a gym-b ased p r o gr a mm e ,
the fol l owing exerc ises were a d d ed : l ati ss i m u s dorsi
• Visit 6
p u l ld o wns; cable p u l l s fo r the trun k r o ta to r muscles :
T h e thoracic s p i n e p a i n conti nued to l essen a n d the
seated rowing fo r t he s c a pu lar retractor muscles: mili
res t i n g LBP was still r a t e d at 3 / 1 0 . The TA ex e rci se s
were p ro g re ss e d to sitti ng (contraction held for 1 0
tary presses for the sho u l d e r m u sc u l a tu r e , i n c ludi ng l a t i s s i m u s d o r s i and serratus an terior; and modil1ed
sec on d s a n d p e r fo r m e d 1 0 times) and by simul tan
squats for the h i p and knee e xt e n so r muscles . E a c h of
e o u s ly raising the o p po s it e a rm a n d leg wh ile i n the
these exercises s t re n g th en muscles that po tenti a lly
fo u r - p o i nt kneel ing position ( Fig. 2 2 . 3 ) . A l t e r n a t e leg
hel p to stabilize the l u mbope lvi c reg ion . Tr i ce ps muscle
l i fts i n sitting were l a te r added ( 3 0 r e p e t i t i o n s ) . Aga i n ,
pus h downs were also added [or variety. The rec o m
To ny r e po rt ed d ifficu lty i n disc i p l i n in g h i mself t o p e r
mended nu mber of repetitions was 3 0 to 5 0 for each
form the rela x a ti o n exercises r egu la rl y.
• Visit
exerci s e ,
w i t h the e m p h as i s on
good
technique.
Diagrams of each exerc ise were p r o vi d ed t o To ny.
7
One week l ate r, Tony re po r ted he had h ad no com
• Visit 9
pla i n ts o f LBP or t h o racic spine pain . He reco rded that
Tony was re - e v a l u a t e d . He was now baSically inde
he was ' q uite a b i t bette r ' on a G l ob a l Rating Scale
p e n d e n t with a h o me-based exer c i se progra mme and
( GRS) between - 7 a n d + 7 ( S t ra tford et a I . , 1 9 9 4) . T h i s equates t o a n u me r i c a l score of + 5 o n t h e GRS,
g y m wo rk - o ut s . P hYSi c a l examina tion revealed that
which has been s ug g es t ed as the cut-off for cli n ica l ly
h ad ach i eved his goal s of retu r n i ng to c ycl ing a n d
i m po r t a n t c h a n ge i n p a tie n ts with LBP ( S tratford
SLR was 8 0 degrees bi la ter a l l y. PPIVM was rec o rd ed a s 3 + thro u gh o u t the l u m bar s p i n e . Usi ng the modi
et a I . , 1 9 9 8 ) . The ZDI sc or e was down to 3 3 / 69 a nd
fie d - mo difie d Schober method , flexion was r eco rded
- 2 cm, wi th minima l
the mRMDQ score was 3 / 2 4 . A Mod i fie d Somatic
as + 3 . 5 cm and exten sion as
Perceptions Q u estio n n a i re (MSPQ; Main, 1 9 8 3 ) was admi n i s tered a n d p rod u c ed a score o f 3. LBP p a t i e n ts w i t h 2m s c o r e s between 1 7 / 6 9 a n d 3 3 / 6 9 and who
thoracic s p i n e motio n . Home exercises were again
reviewed and the stabilization exe rc ise s p r o g r es s ed to i nclude work with a Swiss ball. Tony had no fu rther
score greater t h a n 12 on the MSPQ have a t hr ee - to
questions but was give n the opportu n i ty to contact
fo urfold i ncreased ri s k o f a poor ou tcome (Main et a I . ,
the clinic i f any c o n ce r n s a rose.
REAS O N I N G D I S C U S S I O N A N D C LI N I CA L REASO NING C O M ME N TARY Yo u r manage m e n t at the end of the fi rst
of t h e causes and manage m e n t of h i s p ro b l em .
c o n s u l tation was pri marily aimed at
What reasons did you have for adopting this
edu c ati n g To ny to foster his understanding
approach?
Copyrighted Material
2l ACUTE O N C H RO N I C LOW BAC K PAI N
• C l i n i c ians' answer Pain can be descri bed on the basis o f three compon ents: physica l , emotion a l and ra tional (Paris, 1 9 8 0 ) . The explanation a n d prognosis prov ided the patie n t w i t h a rational basis for u n d erstand i ng t h e p hysical component of his pain a nd thus help to diminish the emotiona l component of the pain (Paris, 1 9 8 0 ) (Fig. 2 2 .4 ) . Extra emphasis w a s placed o n education (or this patient beca use his psyc h osocia l presentation increased the likelihood that he wou l d go on to have persistent pai n . We believe that cou nsell ing patie n ts in this manner helps to lay the fo undation for success fu l p hysical treatment. especi a l ly if the patient has psychosocial dysfu n ctionlimpairmen t or is u nclear of their expected role i n the rehabi litation process. To d a te, Tony had been the recipient o f ' passive ' p hys ical thera py i n terventions: t herefore, cl early defining his i n volvement from the outset reduced the pos sibil i ty o f misund erstanding between the clinici a n and the patient. T h e intent o f t h i s approach is to max i mize the chances of a positive outcome for the patient.
D
Wh at was the rationale underlying the exercises you prescri bed, including releva nt clinical findings?
• C l i n i c i an s ' answer The lumbar s pinal stabilization regimen was initiated to counter the e ffects of mild instab i l ity and an intol era nce to an terior shear forces . Patients with such a synd rome usu a l ly ex hibit ' s haking' o n forwa rd bend i n g , i ncre ased P P I V M ra nge. increased muscle tone in standing, and a n intolerance to static positi o n i n g.
p articu larly a t the end o f the d ay o r follow i n g prolonged activity whe n tissue creep m a y b e a t i ts greatest ( Pari s , 1 9 8 5 ) . A l t hough this patient did not ex hibi t a l l o f these signs, it is possible that the musc u lar guarding could h ave b e e n responsible for mask i n g a ny hypermob i l ity d uring P PIVM testi n g . T h i s was a l so the basis behind the decision not to prov i d e m o b i l i z a t i o n o r m a n i pu l ation treatment. O ' S u ll ivan et a l . ( 1 9 9 7 ) h ave d emon stra ted excellent results i n a clin ica l tria l using speci fic spin a l stabi lization exer ci ses with such d isorders. In this case, a s i m i l a r exercise reg i men w a s u t i l ized. with the foc us on cor rect techn ique and endurance tra i n i n g ( g rad u a l ly increased up to 3 minu tes d u ra tion) . i n ad d i t i on to progressing the level of d i fficulty and fu nctional rele vance of the exercises. Concer n i n g the prescription o f flexion exercises, i t is not u ncommon for patients w i th a s po n d y l o l is thesis to experience agg rava tion of symptoms with exerc ises i nvo lving exte nsion and rel ief with fl exion exercises. This was exemplified by Tony experiencing increased symptoms when sleepi n g i n a prone- lying positio n , thereby p l ac i n g the lumbar spi n e i n exten sio n . The ratio nale for this hy pothesis is the fact that extension of the l u mbar spine produces anterior tra ns lation of the ver tebra l body, poten ti a l ly exacer bating symptoms from the spondylol isthesi s . Theoret ical ly. Ilexion exerci ses should have t h e opposite effect by red u c i n g a n terior shear forces. The prescription o f h amstring stretches wa s based on the SLR testing and the slump test, which su ggested that soft ti ssue restrictions of the hip extensor/knee flexor muscle groups existe d . The aim of stretching these tissues was to address the dysfunctionlimpair ment ( decreased muscle length) and. therefore, opti mize neu romuscular fu nction across the i nvolved j o i nts, potentially reducin g the patient's nociceptive p ai n . The progressive relaxation exercises were pre scribed for pain control, stress and a n x iety reduction, and to assist with the i nsomnia .
II
On reflection. how did the evident psychosocial issues influence you r m anagement of this patient?
F i g. 2 2 . 4 The effects of pain (a) Th ree aspects of pain. (b) An overwhelming emotional concern can block out the physical component and reduce the rational com ponent. (From Paris, 1 980, p. 1 5 7. Reprod uced with kind permission of the publisher.)
• C l i n i c i a n s ' answer This patient was of pa rticu lar i n terest because he presen ted with an ar ray o f symptoms and signs indicative of emotional overlay. that is, a n excessive
Copyrighted Material
C LI N I C A L REASO N I N G I N ACT I O N : C A S E STU D I ES F RO M E X P E RT M A N UA L T H E R A P I STS
emotio n a l compone n t . I n d i vid uals wi th psych osoc i a l
t h e score was a t l e a s t i n pa r t
distress
in h is LBP
h ave spec i a l
req u i reme n ts .
F o r exa mple.
a
resu l t o r i m provemen t
patients who are not s leep i n g we l l bec a u s e of m e n t a l stress m a y conti n u e to d o poo rly from a muscu l oskel e t a l s t a n d po i n t u n l ess the p r i m a ry cause of their mental dysfunctionl impa i rment i s i d e n t i fied a nd a d d ressed . In this i n s t a n ce . To ny req u i red c o u n s e l l i n g b y a men tal h e a l th-care speci a l ist rega rd i n g t h e stress fu l s i t u a t i o n i n h i s h o m e sett i n g . Patie nts rece i v i n g m a n u a l t h e rapy are ofte n seen m o re fre q u e n t ly by the treating therapist t h a n by other mem bers o f the hea lth-care tea m . This a ffor d s th erap i s ts an
id e a l
oppor t u n i ty
for
posi tive l y
i n fl u encing
psyc h o logica l as pects of the patie n t ' s recove ry. by expl a i n i n g the p hys i c a l . emoti o n a l a n d rat i o n a l com
p o ne n ts of their pai n on
rill
ongo i n g basis.
The psyc hologica l compone n t of this patient's pres entation was also m a n aged by the use o f relaxa tion exerc ises . Th i s was speci fically i n tended to proVide Tony w i t h
a
self-management tool for his pain and
stres s . Trea tment regimens that i nvo l ve such
an
h o lis
tic approach are more likely to promote a rapid retu r n to optimal fu nctio n ing lor the p a t i e n t wi t h LBP In a d d i t i o n , by promptly comm u n icating our concerns to the psyc h i atrist a nd the patient abo u t the s i g n ifica n t emotional compone n t i n t h e c l i n i c a l presen tati o n . recovery was fa c i l i tated b y usi ng a team approach. F i n a l ly, beca use of t h e psych osoc i a l issues evidenced
i n this patient,
a
s i g n i ficantly greater amount o f time
was s pe n t educating him regard i n g his pain than would be the case with a patient with pain o f a pre domi n a ntly nociceptive nature. Desp ite
repo r t i n g
a
grad u a l
deterioration
in
h i s condi tion d uring rece n t year s , Tony u n d e rwent c l i n i ca l ly i m p o r t a n t c h a n ges d u r i n g the period he a ttended the c l i n ic. The self-report i n g functio n a l measure
( mRMDQ)
and
depression
i n dex
(2OI)
showed dramatic score red uctions a s To ny prog ressed through therapy. It is su ggested that these tools are practical measures to track chcill ges in the fu nctio n a l a n d psycho l og i c a l status of p a ti e n ts with LB P u nder go i n g trea tment. However, t h e precise reason for th is p a t i e n t ' s initial ly high 20I a nd mRMDQ scores i s u n known . Pa i n symptomato logy c o u l d be a con fo u n d i n g fa ctor for the 20I score and depression c o u l d
be a c o n fou nding factor for the mRMDQ score. W h i l e this pati ent w a s d i a gnosed with c l i n i c a l depress i o n . it could be that the LBP contri b u ted to his o ri g i n a l ly h i g h depressi o n score a n d the subseq uen t de c r e a se i n
• C l i n i cal
reaso n i n g com m entary
The im portance of ' lay i n g the fo u n d a t i on · for a suc cessful outcome through address i n g the patient 's undershmding of the problem (e.g. expl a i n in g the
c a uses and prognosis) and expectat ions of treat ment ( L e . passive versus active role ) is very evident
in the thi n k i n g of t h e expert clinicians. Such an approach should en h a nce t h e patient's ab i l i ty to
make i n formed choices rega rding the p ropo sed act ive programme of reh abi l i t a t i o n .
The exp l a n a tion for the ra ti o n a l e u n d erly ing the
ex
e rc i s e s ( Question 2) ex em pl i l1es t h e three
types of knowled ge that a manual t. herapist must ac c e s s i n su ccessfu l m a n ageme n t of patient prob
lem s . Tbe use of pro posi t i o n a l k n o w l e d ge is evi dent in the r a t i ona le behind the prescription of the s p i n a l st.abi l izati o n exercises , w i th practice vali dated by c l i n ic a l tri a l s . Professi o n a l cra rt k n owl edge supported the implementa tion o f t h e l u m b a r flex i o n a n d hamstrLng stretch exercises . F i n a l ly, pers o n a l k no w l e d ge faci l i t ated
deep u n derstand
a
i n g of the c l i n i c a l p ro bl e m w i t h i n the con text of
the p a t i en t s par t i cu l a r s i t u a t i o n and '
was
l i kely
i n lluential i n the prescri ption of the prog ressive re l a x a tion exerc ises (e.g. red uci n g stress r e s u l t L n g
from d omestic conflic t ) . T b i s overa l l awareness needed by m a n u a l t h era p ists is best achieved in the context of real c l i n ical p robl e m s
The reflec t i o n
a bo
.
u t a n d lea r n i n g from c l i n ical
experiences shown i n t h e c l i n i c i a n s ' d i scussion of
the effect of psychosocial fact.ors on management stra tegy is an essen t i a l part of d e ve l o p in g a rich,
well-organized kn owled ge base and c l i n i c a l rea soning ski J l . However, the cl i n i c a l expert takes rellective t h i n ki n g to
a
h igher level and employs
metacogn i ti o n . reflective appraisal of one 's own
t h i nki n g Metacogn ition is evidenced i n the c lini .
cia n s ' awa reness of the q u a l i ty a n d relevance of the informa tion o b t a i ned through the se l f-r e p o rt measu res a n d their reasoning processes in uti liz ing these measures to u nderst a n d the patient a n d h i s un ique presentation a n d to ach ieve t he goals o f
m a n agemen t . T h e d evelo p ment of c l i n ical exper t ise req u i res a reaso n i n g process tbat i s reflective.
Copyrighted Material
2 2 ACUTE O N C H RO N I C LOW B A C K PAI N
• References j . M . a n d B r i ggl e r. M . ( J 9 9 7 ) . T h e eft'ect of t i me a n d I'req u ency o f s t a tic stretc h i ng o n fl ex i b i l i t y of t he h a ms t r i n g m u sc l e s .
Ba ndy. W. D . . I r i o n .
P hys i c a l Therapy. 7 7 . 1 0 9 0- lO 9 6 . B u rto n . A . K . . T i l l o tso n . K . M . . M a i n . C . I . a n d I-Io l l i s .
S. ( 1 9 9 5 ) .
Psyc hosoc i a l
pred i c tors o f ou t c o m e i n a c u t e
and
s u b c h ro n i c l ow - b a c k tro u b l e . S p i n e .
20. 7 2 2- 7 2 R . D.S. ( I Y Y J I .
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Deyo. R . A . . R n i n v i l l e . I . ; I IHI K en l . I H . . ( 1 9 9 2 1 . "Vh a t c a n t h e h i s t ory < l n d p l1ys i c a l exalll i n ,l t ion t e l l u s a bo u t l oll' back pa i n ? l o u rn a l of t h e i\ lTJ eric'lIl Med i c a l Assoc i a t i o n . 2 h N . 7 6 0-7 6 5 .
Gonel l a . C . . Pa r i s . S . a nd K u t n er. M . ( l 9 8 2 ) . Re l i a b i l i ty i n ev a l u a t i n g [las s i ve i n te rver t e b ra l m o t i o n . P hy s i c a l
j o u r n a l o f Psyc hosom a t i c Re s e a r c h .
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the c l i n ica l manual
Hypothesis generat i o n i n
2 7 . 5 0 3-5 1 4 . M a i n . C . I . a o d Wa d d e l l . G . ( 1 9 8 4 ) . The
reaso n i n g beha v i o r of
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thera pists. J ou r n a l o r PhYS ical Therapy
detection o r
i n c h ro n ic low b a c k
e v a l u a te t h e r i s k o f poor o u tc o m e . S p i n e . 1 7 . 4 2 -4 9 . M c K i n n is . L. ( 1 9 9 6 ) . Funda m e o t a l s o r O r t h oped i c R a d i o l ogy. La n sda l e . PI\ : 1 '. 1\ . Dav i s . M c l w c k . I{ . ( 1 9 7 =; I . T h e McC i l l p il i n q u e s t i o n n a i re : rnajor prope r t ies a n d sc o ri n g m e t h o d s . l'iJ i n . 3 . 2 7 7-2 9 9 . Moo ney. V. ,I n d Roberts o n . J. ( 1 9 7 6 1 . T h e
1 J . 40-4 5 . Iv! . a n d M o r r i s . H . ( 1 9 8 3 ) .
Educ a t i o n . Ro l a n d .
A
study of t h e n a t u ra l h i s tory of l o w bil c k p a i n .
re l i a b l e
Par t
I : Devel n p m e n t o f
low-back p a i n . S p i n e . 8 . l 4 1- 1 44. S t rat ford . P I"'. . B i n k ley. J . . Sol o m o n . I? ct a l . ( 1 9 9 4 ) . Assess i n g cha n ge over time in pa t i e n t s w i t h l o w back pn i n . Physi c a l T h era py. 7 4 . 'i 2 N-S n . S t r a t ford . I'. W. . Gi n k l cY. I . . l� i d d le . IJ L. a n d C U Y il t l . C . f l . ( I Y 9 N I . S e n s i t i v i t y to c h 'l I1 ge o r t h e l{ o l ; ll1 d - M o r ri s 1 l ; l l' k I '; l i n Q u cs t i o n n ;l i re Pa r t I . P hy s i c a l Thera py. 7 R . J 8 6- 1 9 6 . W'l d d e l l . C . ( 1 9 9 8 ) . The /3,l ck ! 'a i n
ra cet s y n d rome. C l i n ic a l O r t hoped i c S
Revol u t i o n . Ed i n b u rg h : C h u rc h i l l
il nu
Livi ngstone.
R e l a ted
R es e a r c h . 1 1 5 . 1 4 9 - 1 5 6 .
a
a n d s e n s i tive me a s u re i n
Wa d d e l l .
R ad i o logy : A Pract i c a l Approac h . 2 n d
B. ( 1 9 9 2 ) . M u n u a l T h e ra py. · NAGS · . · S N AG S · . ' P R P S ' etc. IVe l l i ngto n . New Zea l a n d : P l a n e V i e w
ed n . Londo n : L i p p i n cott-Ra ve n .
Press .
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Therapy.
0 2 . 4 3 6-444.
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Greensp;m . A . ( I Y 9 2 ) . O r t h oped ic
H a mpton A t k i n s o n . I . . S l a t er. M . A . .
Wi l l i n m s . R . A . e t a l .
(J 9YR). A
p l a cebo-con tro l l ed ra nd o m i he d t ri a l o f n o r t r i p ty l i ne
It)r c h ro n i c
l o w b a c k pa i n .
Pa i n . 7 6 . 2 1l 7-2 9 6 . I nman.
VT.
a n d S a u n d e r s . ) . 13 . ( 1 9 4 4 ) .
or
Nervo u s ilnd
Mental Disease. YO. 6 6 0-6 0 7 .
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19
3 1; ) . P ro gres s i ve
Rel a x a t i on . 2 n d ed n . C h i c a go . I L : U n i versity o f C h icago Press . l u l l . G . A . a n d R i c h a rdso n .
C.A. ( 1 9 94).
Reh a b i l i t il l i o n o f a c t i ve s t a b i l i z a t ion o f
t h e l u mb a r spi n e. I n P hy s ic a l Tb erapy
or
the Low B a c k .
a n d J. R.
Tay l or.
2nd
EB . . Twomey. L . T. a n d ( 1 9 9 7 ) . Eva l u at i o n of
A l l ison . G T
edn ( L . T. Twomey
cds. I pp.
2 5 ] -2 7 4 .
Ed i n bu rg h : C l1 u rc h i l l Li v i n gs t o n e .
J. H . ( 1 9 3 8 ) . Obse r v a t i o n s on refe r red pain ari s i n g fro m m u sc l e . C l i n i c a l Sc i e n c e . 3 . 1 7 5- 1 9 0 . Magee. D.J. ( 1 9 9 2 ) . Orthopaedic
KeiJ g re o .
Assess m e n t . 2nd ed n . Lond o n :
Sau n d er s . M a i n . C.I. ( 1 9 R 3 ) . T h e Mod iJl ed So m a t ic Perce p t i o n s Q u e s t i on n a i re (MSPQ).
C . . McCulloc h . ) . A . . K u m m e l . E. IUv!. ( 1 9 7 9 ) . N o n orga n ic
Ve nn er.
p hysi c a l s i g n s in low- b a c k p a i n . S p in e .
spec i l1c stab i l i s i n g exerc i s e s in the
Morris D i s ab i l i ty Que s t i o n n a i re. P h D
tre a tmen t o f c h ro n i c low b a c k p a i n
T h e s i s . U n i ve r s i ty o r
St A u gus ti n e.
FL. U S A . We i nste i n S . L . ( 1 9 9 5 ) .
Defo r m i t ies o r
w i t h radiologic d i a gnosis o f spondylo
Refe r red pa i n fro m musc u l oske l e t a l s t r u c t u res. j o u r n a l
O·Sullivan.
and
lysis . S p i n e . 2 2 . 2 9 5 9 -2 9 6 7 .
Paris . S . v. ( 1 9 1l 0 ) . M a n u a l therapy: Treat fu n c t i o n not p a i n .
In
I n ter n a ti o n a l
Perspect i ves i n P h y s i c a l T h erap y
( T. H . M i c h e l . ed . ) pp. 1 5 2- 1 6 7 . Ed in bu rgh : C h u rc h i l l L i V i n gstone.
Pa ris. S.v. ( 1 9 8 5 ) . P hysica l signs of i n s t a b i l i ty. S p i n e . 1 0 . 2 7 7-2 7 9 . Pil ris. S . V ( 1 9 9 7 ) . S p i n a l Stabil iza t i o n : L u m ba r S p i n e . U n d er s t a n d i n g a n d Tre a tm e n t . S t Au g u s t i n e . FL: U n iversi ty o f S t A u g u stine Inst i t u te ['re5s.
Weinstein. B.L. Ryd e v i k a n d V K . H . S o n n t a g . eds . ) pp. 1 9 5-2 3 0 . (J .N.
Lo n d o n : Rave n .
W h i te. A A . . Ber n ha d t . M . a n d l'a n j a b i . M.M. ( 1 9 9 9 ) . C l i n i c a l b i o m ec h a n ics and l u m b a r s p i n a l i n s tab i l i t y. In Lu m b a r Segm e n t a l I n s t a b i l i ty ( M . Szpa l s k i . R. G u nzbu rg and M.H. Pope, e d s . ) pp. 1 5-2 5 . Lo n d o n : L i p p i ncott W i l l i a ms & W il k i n s .
R . . B i n kley. J . . B o l c h . R . e t a l . ( 1 9 9 3 ) . Re l i a b i l i ty o f the mod i fl ed mod i fied S c hober and d o u b l e
Wi l l i am s .
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and Lo u be r t . P.V. ( 1 9 9 0 ) .
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FL:
U niversity o f
S t . A u g u s t i n e Instit u te Press.
( 1995).
Assess i n g h e a l th-related
q u a l i ty o f l i fe
in
patie n ts
wi th
i n c l i n o meter m e t h o d s for me a s u r i n g
l u m b a r fle x i o n a n d exte n s i o n .
Pil t r i c k . D.L .. Deyo. R.A .. Mi a s . S.j. et a l .
S p i ne .
t h e s p i n e . I n Essen t i a l s o f t h e S p i n e
sc i a t i c a .
2 0 . 1 8 9 9- 1 9 0 9 .
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Physica l T h erapy. 7 3 . 2 6-3 7 . Zung.
W. W. K . ( 1 % 5 ) . A s e l f-rati n g
d e pre s s i o n sca l e . Arc h i ves o f G e n e r a l
Psych i a t ry.
1 2 . 0 3 -70.
C H A PT E R
A n o n - m u sc u l os ke l etal
23
d i so rd e r m asq u e rad i n g
as
a m u sc u l os ke l etal d i so rd e r Peter E. Wells
�
S U BJ E C T I V E EXAM I N AT I O N
S teven i s a 4 8 -year-old self-employed g raphic designer. He attended for a physiotherapy consultation regard ing his low back and left leg pain . r met h im firs t whi le he was Sitting
in the waitin g room of the c l i n ic and
asked him to accompany me. He got to h i s feet w i t h s l i g h t d ifficu lty and carried a s tick, w h i c h h e used t o walk a n d w h i c h h e said helped i f his back w a s bad. S teven was overweight bu t not obese and walked with a w ide base. His right leg moved awkwardly (Le. without norma l rhythm) a s he walked and he seemed u nable to lift h is right foot easily. S teven s aid he tripped in the s treet
1 0 weeks previ
ously and had fallen fo rwards with his hands i n his pockets , more towards his right side. He had been unable to break his fal l but he had not lost conscious ness . He cUd not lmow why he had tripped but thought he may have stubbed his foo t agai n s t a paving ston e. At the time, be felt u n h armed by the fal l , but over the fol lowing 3 days he developed ills symptoms (Fig.
23. 1).
His main sy mptom was a n intermittent left-s ided mid- to-low lumbar deep ach ing , which when espe C i a l l y severe would spread across to include his right s ide. This pain wou ld radi ate bilaterally toward s h i s oute r h i p s , over the area o f the g reater troch an ter. A fu rther less-severe pain radiated posterio rly and down thro u g h h is left b u ttock, posterior thigh and calf b u t d i d not extend i n to his foot. This w a s a l s o intermittent and of a deep aching
Fig. 2 3 . 1
Area of patient's symptoms.
qu ality. The postero la teral aspect
o f his left c a l f fe l t ' extra sensitive ' and the th ird and
his foot dropping toward s the e n d of the day, and he
fo u r t h toes of his l e ft foot were perceived as sli g h t ly
had some d ifficulty in using his right leg.
numb. S teven had had no p a i n at a l l in h i s r i ght leg but
In add i t i o n to the low back and leg sy mptom s ,
commented he was dra gging the leg as he walked , with
Steven reported that a b a n d of l e ft-s ided thoracic
352
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23 A N O N - M U S C U LO S K E L ETA L D I S O R D E R MASQ U E RA D I N G AS A M U S C U L O S K E L ETA L D I S O R D E R
'
e l ec t r i c se n s it i v i ty occ u r r e d in term i ttent ly, exten d '
ing from t h e lower border o f h i s left sc a p u l a to his l e ft
thoraco l u m b ar l eve l . His arms had no symptoms excep t for a feel i n g of in cre a s i n g we akness i n h i s ri g ht h a n d and an i n termitte n t ache over the d o r s u m of t h e h a n d . Because of these symptom s , he was fi n d i n g
i t d i ffic u l t t o h o l d a pencil p rope r ly d u r i ng h i s des i g n work . He also repor ted some i n termi ttent swel l i n g
ng over t h e dorsu m of h is l e ft h a nd F i n a ll y, ex pe ri en ced ach i n g across his upper t h or acic region and the s u p er i or a spec t of bo t h sc a p u l a e but this h a d i m p ro ved w i t h prev i o u s treatme n t . He
a nd
a chi
.
S te ve n h ad
,
h a d had no n eck or h e a d pa i n , n o r thro a t , c hest, or abdo m i n a l sympto m s . The
fr on t 0 1' his l e g s and h i s
feet were symptom -free , e x c ep t fo r t h e t w o t o e s o f h i s left foot. S ince the fi r s t week
following h i s fa l l Steven's symp
toms had rem a i n ed fa i r ly static, but v a ry in g some wh a t . At presen t, a l l his symptoms we re s l igh t ly easier. Initi a l ly he had sought h e l p fro m a n os teopa th and received a series of treatments, which he described as c r ack i ng and crun ching' o f h is n ec k and s ho u l d er reg ions. This eased the pain he originally fe l t in this area b u t h a d not a ffec t ed his other areas o f symptoms . '
� I J -
D
The osteo path had recommended he co n s u l t a n e u ro l ogist; therefore. he firs t wen t to his ge ne r a l practi tioner (GP) to d iscuss the n eed for a refer r a l . After S t e ve n compl a i ned o f u nreso l vin g Imv b a c k p a i n , the docto r di scussed his wei ght and g e neral lack of fitness; however, no referral was provided . A fr i end h ad rec ommended he try p hysi o therapy tre a tm e n t . His l o w back a nd l eft leg p a i n were e a s e d b y lying s u p i ne b u t were a g g r av a ted by s t an d i n g a n d wa lki n g such tha t even a fter walki n g 1 0 0 m bo t h h i s p a i ns i n c r e a sed m a rke d ly and h i s r i g h t leg felt weaker. Wo rk i n g seated on the edge o f h i s s to o l s i m i l a r ly increased his back and then leg p a i n . When q u est i o n ed a b o u t his g e n e r a l hea l th , Steven r e po r ted h a v i n g h i gh blood pressure. w h ic h was con trolled by medi c a ti o n . He s u ffe r e d from go u t for wh ich h e was presc r i b e d a llop ur in o l and he had also taken i b u pr o fen occ a s i on al ly over the previous weeks bu t with little effect. He was n ot d i a bet i c a nd h is we ig h t w a s s tead y No r a d i og r a p h s had b ee n tal<en of h i s spine. Coughing and sneezing did n o t affect any o f h i s symp toms and micturiti o n was normal tho u g h s low. He h a d not s u ffered from any d izz i n ess . T he on ly repor ted .
,
.
n u m b ness was of the toes of his left foo t .
R E A S O N I N G D I S C U S S I O N A N D C L I N I C AL R E A S O N I N G C O M M E N TA RY
What were your i n itial thou ghts on meeting the
been
patient? H ow did you i n terpret his symptoms
time h e
and your ea rly observations?
II
• C l i n i cian's answer m eet i ng the p a tient was that he in te l li gent good h u mo ur ed m a n wh o , to some e x te n t , m ade l ig h t 0 [' his prob l e ms and seemed to h ave no idea at a l l as to how serious h i s co n d i t i o n m i g h t be. r was be g i n ni n g to s uspe c t some for m of tu mo ur the type and l oc a t i on o f wh ich I w a s not sure. The weak ness of his ri g ht h a nd and h is incre asing diffic u l ty h o ld i n g a p enc i l l e d m e t o t h i nk t h a t wh a te ve r pa t h o .
You have spent consid e ra ble time mapping the patient's symptoms. What were your reasons
My in i ti a l t h o u g hts on was a n
caused by a l u mbar disc a l i nj u ry susta i n ed at the tri pped a n d fel l .
-
for doi n g this? Did you have a ny thoughts regarding the pain mecha nisms involved in this presentation?
• C l i n i c ian's answer
.
log ic a l process was going on it mu st be below his mid cervical s p in e
.
I also
considered m u lt i p le s cle ros is.
r e me mberi ng t b at pain . i n c l ud i n g backache, is occa siona l ly
an e a r ly symptom (Porth, 2 00 2 ) . F i n a l ly I ,
hy po t h esi z ed t h a t h i s back and left leg p a in may have
I suppose that a l re a dy because of his gait p a t ter n , I w a s enterta i n ing t h e notion t h a t there m i g h t be some upper motor n e u r o n component to his disorder and I was i n i ti al ly lookin g fo r clues in t he distribution a nd n a t u r e o f h i s symp t o m s . I n te r es t i n g ly the pa tient ,
,
repor ted that
t h er e were no symptoms s u c h as ' p i n s
a n d need les ' in the soles of h i s feet, w hich are often co n s i de red
Copyrighted Material
a n e a r ly sign o f cervical m ye l op a t hy
C L I N I C A L REASO N I N G I N ACT I O N : C A S E STU D I E S F RO M EX P E RT M A N U A L T H E R A P I STS
( M a i t l a n d e t a l . . 2 0 0 1 ) . I thought t h a t . whatever the u nd e r ly i n g cause. there was a n e u rod y n amic compo n e n t to h i s d i s o r d e r.
This was s u gge s te d by the
• C l i n i cal
reaso n i n g c o m m entary
It is in teresting
to note that the c1i nicicUl has from the the almost i n ciden t a l llnd i n g of
pain a n d pa r a es t h e s i a e xt e n d i n g t h rough h i s l e ft t h o
out set focu ssed on
racic p a r a s p i n al a re a . left l u mbosacral region a n d le ft
l i m b wea kness. despite the pa t ien t ' s main comp l a i n t
leg. The w e a kn e s s ( , d ragg i n g ' ) o f h i s ri g ht le g a nd the
being that of back pa i n . He has recognized t he po t en
we ak n e ss
tial significance of this fi nding a n d h a s immedia tely
of his right h a n d were . to my m i n d how
ever, more wo r ry i n g aspects of h is d isorder.
hypoth esis of a d i sorder the condu ctivity of the eNS wh ile m a ppi ng the patient's symptoms. This early recogn it ion of ' red tla g s ' is important bec ause i f his suspicion gains fu r t h er supportive e v i de n ce then certain physical examination a nd treatment p r oced ure s a r e consid ered contraindica ted for the time being u n ti l further med ical i n ve s ti gat i on is u ndert aken. as they m ay worsen his condWon or at the vcry Icast del ay the proceed ed to test h i s pri m ary
a ffecting
D
What spec i fi c tests d i d yo u th i n k were i m p o r ta n t to i n c l u d e i n the p hys i c a l exa m i n a tion and what were yo u r rea s o n s fo r p l a n n i ng to i n c l u d e th e m ! Did you c o n s i d e r th e re were any p reca u t i o n s o r co n tra i n d i cati o n s to a ny part of the p hys i cal exa m i nati o n !
implementation of appropriate t reat ment.
• C l i n i c i a n 's answe r
centra l nervo us syste m ( C N S ) i n p ar t.ic u l ar.
n states t h a t he i n t e n t i o n a lly plans This may wel l sound t o some a s t h ough he i n tends to u n dertake a n i n c o m ple t e p h y s i c a l exam i n a t ion , poten t i a l ly i n c r e a S in g the risk of m issi n g i m p or t a n t
Howeve r. I pl a n ned to be c a u tious w i th regard to his
i n formation or biasing t he exami n a t i on toward
S i nce I w a s
su sp i c i o u s of a
The
c en
tr a l neurol ogical d is
order fro m early o n in the consulta t i o n . I proposed to ' c u t corners' in the p hysica l e x a m i n a t i on to foc u s on the
c l i n ic i a
to ' c u t corners' in h i s physical exami n a tion .
CNS and t h e fo rces I mi ght i m pose upon it d u ri n g
his favoured hy p ot h e s i s a n d , t h crefiJre. only paying
exa m i n a tion . My s u spicion of the poss i b i lity of a ' cen
lower-ra nked d isc leSion ) . However, it is more tha n likely he w i l l a c t u a l ly e n h a nce his effi
tra l l e s i o n ' without a ny Imowledge of the underly ing
pa th o l og y ca used me to worry. I p l a n n ed to ex ami n e his
CNS specific a l ly. as we l l as h i s peripheral nervous stand ard upper motor neuron cl i n ical
'
l ip serv ice' to tIle a li)remen tioned
hypotheses (e.g. lu mbar
ci e nc y in conducti n g the physic a l exa m ination by
testi n g procedu res (e.g. Ba bi n s ki and clonus tests ) . The
' cu t t i n g co rn e rs that is by employ i n g ' m a x imizing ' p ri n ci pl e s . as he has ample clin ical experience to
the
recognize and avoid such errors of c l i n ic a l reason
system , using
poss i b i l i ty of a cervical d isc lesion, perhaps in
' ,
process of worsen ing. a ls o meant I need ed to be c a u
ing. I n fact. the lise of maximiz i n g princ iples i s
t i ous with ac tive ce r v i c a l s pi n a l mo bil i ty testi n g .
of the h a l l marks of expert c l i n iC i a n s and
O t h er p hy s ica l ex am i n ation proced ures t o be per
one
helps to
promote efficiency and accuracy of their c l i n ical
formed i n cl uded ac t i ve l u mbar sp in e nexion and ex ten
reasoning. I n this case. s a fety i s foremost
sion. particu l arly b u t not exc lUSively as
to be employed , a ga i n to assess for poss i b l e neu ro
idem 's m i nd and wh i l e hypotheses i n all categories (see Ch . 1 ) are, or c o u l d be. con sidered . the focussed p hy s ic a l exami n ation i s to be d irected toward the testing of hy p o t h e s es re g ard i n g poten tial s i n ister pathology as the source of t he symptoms , wh i le beari n g in mind the precautions and contraind ica
dy na mic c o m ponen t s .
l ions to p hysical exa m i nati o n and treatment.
m a r ker s for
a po s s i b l e disc l e s i o n . The ad d i ti o n of cervica l flex i o n t o l u mb a r flexio n w a s
to be Llsed t o te s t for any n e u r o
dyna m i c c o m p o n e n t to the d i s o rder. Passive straight leg raise
tE
( SLR ) and pas sive n eck nexion tests were a l s o
on
the clin
P H YS I C A L E XA M I N AT I O N
A n alysis or Steve n ' s gai t showed he wa U<ed w i th
a
rat h er wide base of support and he re p o r ted fee l ing u n stea dy without ills stick. His rig h t leg looked
hy per to nic in that the k ne e d id not l1ex norma l ly during a circumduction movement. His foot likewise appeared not to dorsiflex
the swing phase a nd he pe rfo r m ed
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23 A N O N - M USCU LOSKELETA L D I S O R D E R MASQ U ERAD I N G AS A M U S C U LO S K E L ETA L D I S O R D E R d urin g the l i ft off a n d swing phases. Steven appea red to
Pass ive SLR was to 80 degrees o n the l e ft and pro
be unable t o l i ll his right foo t clear of the g round w i th
d uced no pa i n . Howe ver. u po n t h e a d d i t i o n o f a n kl e
each step. H i s gait. t herefore. suggested the presence of
. dorsi ll e x i o n . a
to
stretc h i n g p a i n w a s provoked down t h e
extensor spasm. Bal a n c i n g o n h i s l e ft leg was stea dy. b u t
leg similar
he wobbled
sided passive SLR was l i m i ted Lo 6 0 deg rees by a
when a ttempti n g t h e same on t h e r i g h t leg.
Ac tive spi nal moveme nts i n stand i n g were tested .
S teven's fa m i l i a r d eep ach e. H i s r i g ht
m a r ke d [ee l i n g or h a rd resis tance.
Forward bendi n g of t h e t r u n k was l i m i ted by inCl-eas
T h e n e u rolo g i c a l ex a m i n a t i o n revea l e d bilatera l
ca l f
His rig h t
ing l ow back pel i n . with h i s fi n ge r t i ps j u st reac h i n g his
moderate
t i b i a l t u beros i ties . A d d i t ion o r cervical llex i o n Lo t h is
a n k l e dorsiflexors a n d ever tors were a lso considerably
movemen t prod uced some p a i n i n to the l e ft buttock .
wea k . T here was dec reased sensation to l i g h t tou c h
musc l e wea kness in s t a n d i n g .
Tru n k ex tension was l i m i ted by s t i rrness at 20 deg rees .
a n d p i n prick t h r o u g h o u t h i s left l e g . Te nd o n re flexes
with
at the a n k l e a n d knee were hy per-refl ex i c b i l a tera l ly.
some
cen t ra l low b a c k pa i n reprod uced . S ide
bendi n g to t he l e ft was restric ted but pa i n l ess. wh i le mov i n g to t h e r i g h t p rovoked r i g h t-sided
l ow
back p a i n
a nd w a s l i m ited . m a tely 7 0 deg rees i n ra nge a nd
o
a
pos
i t i ve Babi nski reflex ( u pgoi n g big toe ) was prese n t b i l atera l ly. A t t his stage t h e phy s i c a l exa m i n ation was
In s u p i ne l y i n g . pass i ve neck Il ex i o n
m
A n kle clonus was prese n t on the r i g h t side a n d
was
was
appro x i
c o n c l ude d .
symptom-free.
R EASO N I N G DI S C U S S I O N
What was you r i n terpretation of the S L R
hypotheses were y o u enterta ining a n d what
fi n d i ngs, parti c u l a rl y the end-feel?
findings su pported and refuted each hypot h e s i s ?
• C l i n i c i an 's answe r
• C l i n i cian's an swe r My in terpretation
of of
the l e ft S LR was i n kee p i n g w i t h
The ex aminati o n was stopped bec a u s e
of
the sign ifi
sensitiv ity
c a n t respo nses el icited d ur i n g my basic neurologic a l
( m ec h a n ical or p hy s i o lo g i c a l ) . It was not. a t a l im i t a
exami n ation. M y p rimary hypothesis was that these
the
hy poth esis
i n creased
n e u ra l
tion o f 8 0 deg rees . typ i c a l of d i s c a l compress i o n . The restricti on
on
the right side was . i r a ny t h i n g . more
upper motor neuron res ponses to testing were c a u sed by
a
space-occu pying lesion hi g h in the spinal c a n a l !
It h a d to be a cerv i c a l or c e r v ico thoracic l e s i o n t o of t h e ri g h t hand . A l ternatively.
i n teres t i ng. It was. i n s p i te o f the patient h avin g no
cord .
pain i n t h e righ t l e g a nd the fac t that the back p a i n
produce t h e weakness
was wo rse o n t h e l e ft s i d e . s i g n i l1ca n tly m o r e l i m i ted . T h e e n d - feel
of
the ri g h t SLR . a very h a rd res ista nce
I tho u g h t tha t perhaps mu ltipl e sclerosis was
a
poss i b l e
d i a gnosis/second ary hypo thes i s . particularly as i t may
o r block to movem e n t . suggested a powerfu l g u a rd i n g
prese nt \"li t h low back pain as an i n itial symptom.
re a c ti o n .
A l tho u g h the relief obtained in t h e supi ne-lying posi
II
What were yo u r reasons fo r ceas ing your
ord er. i t
exa m i n ati o n at th is time? Specifi cally, what
I cannot claim a ny g reater insight than this.
tion might su ggest a d iscogenic component to t h e d i s
is o(
mar kedly lesser clinical s i g n illc a nce.
to not a l ar m him it was su ggested to h i m t h a t some ' n erve irrita t i o n ' needed It was exp l a ined to Steven that the exami nation
so
rar
to
b e looked in to before any
further phys iotherapy could be consid ered a n d the
was telephoned of h i s
i n d i c a ted t h a t the weal<ness and num bness a n d the
sooner this was done the better. The GP
d istu rba nce of ga i t were more impor t a n t fea t u res to
at
i nves tigate t h a n the back and the l e g p a i n . In order
prese n t a tion was d i s c u ssed . A n a ppoin t me n t was
this
pOint a n d the need for an u rgent rev i e w
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C L I N I C A L R EASO N I N G I N ACT I O N : C A S E S T U D I ES F RO M E X P E RT M A N UAL TH ERAPI STS
made for the p a t i e n t to attend the doctor's su rgery the
pro l a p se at C S--C 6 co m pressi ng the spi n a l cor d He
next mo r n in g and t h e consultation was concluded.
u n de r we n t
Followi n g this visit to h i s GP, S teven was u rgen tly refer red to a neuros u rgi cal hospital. A ma gn etic reso
.
a
cerv i ca l d iscectomy a nd fu s ion ( Cl ow a r d
proced u re ) a rew d ays l a ter a nd was su bsequently placed in a rirm c o l l a r.
nance i m a g i n g scan revealed a maj o r cerv ic a l di sc
REASO N I N G D I S C U SS I O N A N D C L I N I CAL REASO N I N G C O M M E N TA RY
D
C om m u n i cation was o bv i o u s l y a key part of yo u r m a n age ment at th i s s tage . W h at were yo u r m a i n c o n s i d e rations i n yo u r conversati o n s with the patient and the do cto r, bearing in m i n d that the d o ctor had m i s s e d the n e u rological fi n d i ngs !
• C l i n i c i a n 's an swe r
• C l i n i c i an's an swe r A l l s ymp to m areas
a p p eared
w i th i n 3 d a y s a fter the
p atien t ' s fa l l , not h a v i n g been presen t beforehand. His ga it had worsened since. as had his ri g h t h a n d weak -
n e s s . It seems likely the fa l l h ad provo ked or severely wo rsened the u nd er ly i n g c a u s e of his prob le m He .
was a heavy m a n a n d probably the v io lence of his fa l l ,
Main ly, I did no t wa n t to ala rm the p at i e n t T h is was
pe rhaps w i t h a w hiplash like e ffect on h i s neck ,
beca use:
c a u sed the d is c a l prolapse.
.
• there was n o point si nce he was be in g seen by h is
-
Once I knew the d i ag n os i s a nd s u rgery had been perfo rmed, I th o u gh t fu l l recovery o f norma l arm and
d octor the fol l o w i n g d ay • t here was n o th i n g to be gained by ala rming or
leg function was u n l ikely altho u g h I hoped residual
wor r y ing the patient, who might then h ave pa ssed
paresis and spastici ty wo u l d be mi n i m a l . The extent of
a distressing
24
h o u r s before seeing his docto r
• I d id n o t consider it w i t h i n my rem i t as a phys i o
ne u rologic al
recovery
is
n oto r i o usly
d i ffic u l t
to
predict, espec i a l ly i n the long term, a nd I held out hope
thera p i s t to raise the p o ss i b i l i ty of various med i c a l
t h at even over several years any neuro l ogical deficit
diagnoses, a l l of w h ich were ser i ous
mi g h t improve fu rther.
.
My only co n sideration in speaking to the doc tor was to impress on him the urgency of the si tu ati on so t h a t the patien t could be diagnosed without del ay and appropri ate medical or su rgical intervention instituted at t he
earliest p oint
in time. I was very diplomatic, em phasiz
in g that the patient appeared to h ave con sid e r ab ly worsened since his consultation with the doc tor, and stating my fmd ings of upper motor neu ron signs
.
The doc t or , for wh a tever reas o n , did n o t appear to rea lise the u rgency of the situation a n d I h a d to i n s i s t o n the patient b e i n g s e e n the fo llo w i n g d ay. I to ld h i m t h a t my ' g ut fee l i n g ' w a s t h a t t h e patient h a d a very serious pa thology that would brook no d ela y. The doctor n ever contac t e d me a fter he saw the patient.
II
,
• C l i n i cal
reaso n i n g commentary
' G u t feelin g is a term co m m o n ly '
used by
clinicians
for describing a v a gu e nagging se n s e that a particu ,
l ar clinical impression
or
cou r s e of act ion is correct .
d espite incomplete or equ ivocal evidence. It is also sometimes referred to as 'cli nica l i n tu ition' and is o ften dismi ssed as bei n g an u nscicntillc
a nd su bject
ive h u n c h The expert c li n i c i an , however, has learnt .
to heed such
feelings, as
i n this casco The clini c i a n
had d iscovered th rou g h reflection on hi s own clini
cal experiences that this ' inner prompt i ng' , perhaps c au se d by the subconscious recogn ition of a pre v i ously en c o u n t ered
clinical cue
or patter n , should
not be ignored and warran ted closer attentio n .
Intuitive skills h a ve been recog n ized as
O n refl e cti o n , were you able to i d e n tify
an
any fa ctors that c o n t r i b u ted to the
i mp o r ta n t p a r t of expert c l i n i c a l reaso n i n g and
d evel opment of this p ro b l e m ! What was
have
yo u r p rogn o s i s !
cific patient cases.
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been
l i n ked to cl i ni c a l experie nce with spe
23 A N O N - M U S C U L O S K E L ETAL D I S O R D E R MASQ U E RAD I N G AS A M U S C U L O S K E L ETA L D I S O R D E R
'Outcome
improve. His g a i t was less spastic but he continued to n e ed a s t i ck in order to walle The strength and coordin
Five weeks after his spinal surgery, Steven w a s referred
a tion of his h ands had improved greatly. Nevertheless,
back for a physiotherapy assessment of his gait and gen
Steven remained considerably disabled. He also con
eral mobility problems . He was beginning to show
tin u e d to have low back stiffness and aching, with occa
improvement in his hand function but progress in the
sional a c hing down his left leg, for which he received
fu nction of his legs wa s much slower. Rehabilitation
treatment. His ne u ra l provocation tests, such as passive
w a s u ndertaken over the following 3 months to facili
SLR, remained quite restricted , but at the time of his
tate an improvement in his coord i n ation and ba lance.
d isc harge
At 6 months after surgery. his condition ceased to
symptoms .
were not associated with any ongoing
• Refe re n ces M a i tl a n d . G o o Hengeve l d . Eo o B a n ks. K. a nd E n g l i s h K. ( 2 OCJ l ) . M a i t l a n d 's Ve rtebral M a n i p u l at i o n . 6 t h ed n . Oxford : B u tterwo r t h-Hei n e m a n n .
Por t h . C . M . ( 2 00 2 ) . Path o p hysiol ogy.
Concepts of A l tered Hea l th States. 6th ed n . Lond o n : Lippincott
Williams &Wilkins.
Copyrighted Material
C H A PT E R
24
Fo rearm pai n p reve nti n g l e i s u re activiti e s
Israel Zvulun
� Dan is
S U BJ E C T I V E E X A M I N AT I O N
a
5 1 -year-ol d married man w ith truee c h ildren
who has been
refer red for phy siotherapy
was mainly related [0
a
genetic pre d i sposi t i o n . Dan
by an
reported that since the surgery he had n o time for
orthopaeclic surgeon who had diagnosed 'cervical
regular exercise, although he was aware o f the import
d iscopathy at the C 6-C 7 level with radiculopathy ' .
ance of cardiovascular fitness. His mother. a ged 82 ,
Dan i s the owner o f a material factory specializing in
had suffered th ree myoc ardial in farctions and had a
exclusive cuttings for the clothing market. He h as
heart function i n g at 3 s uIr, of maximal capacity. His
worked fo r 2 0 years as the manager of the factory
father died or lu ng cancer
and h as been subj ected to intensive and stressful
was the first time Dan h ad suffered from any problem
working conditions beca use of market demands. His
in the u pper q u a d r a n t . In t he past. h e had experi
at a relatively young age. This
o n ly leisure activity was during weekends, when he
enced a backache and dealt with the pa in by use of rest
used to ride a Jet Ski for 2-4 hours . Since the onset of
and analgesics. Dan had not received a ny physiot her
the recent problem he had stopped that activity.
apy treatment previously. The orthopaedic su rgeon
Fou r years before the commencement o f the pre
did not prescr i b e any medications but recommended
senting cond ition. he underwent open-heart surgery
a cervical collar, cer v ical mobilization, ultrasonic
for coronary heart disease. There was no history of
th erapy and transcutaneous electrical n e r ve stim ula
smoking or poor dietary hab its and the heart disease
t i o n (TEN S ) .
REASO N I N G D I S C U SS I O N AN D C L I N I CAL REAS O N I N G C O M M E N TA RY W h a t were you r i n itial thoughts based on the pati e n t's p rofi l e ?
that m ight include pain in the posterior neck area, radicular pain referred distally, paraes thesiae and other neurological signs and symptoms. However. other hy po theses related to the anatomical sources of the
• C l i n i c ian's answe r
symp toms had to b e considered. These in cluded the
Med ical diagnoses [or many musculoske letal condi
extensor/sup i n a tor muscle group of the wrist. the radial
tions are very often non-s pecific (e.g. neck pai n , cer
nerve at the arcade of Froshe. the elbow and prox imal
vicobrac h i a l g i a ) . The med ic a l d iagnosis in this case
rad ioulnar joints, referred p a in from the shoulder, and
descri bed a very specific condition (clinical pattern)
the wrist j o int.
358 Copyrighted Material
24 F O R E A R M
Referred p a i n o f viscera l origin cou ld also be a source of the symptoms ( his father d ied of a l u n g cancer) . Pancoast's t u m o u r ( tu mor of the l u n g apex) can refer pain to the forearm a nd can m im ic a C 8 -T 1 nerve root lesion. Thyroid carci noma or other s i te occupy i n g lesions of the neck and throat can a lso spread metastases Lo the brac h i a l plexus and cause referred symptoms to t h e forearm. However. these usually manifest in a n on-dermatomal distribution as op p osed to nerve root syndrome. The heart d isease might h ave served a s a visceral origin lo r the forearm pai n . This may h ave occur red through the sensitization of nocice ptive a fferents of the heart by ischaem i a and the tra uma of surgery. whic h may. in t u r n . irritate convergent a fferent neu rons from the u pper l i mb and ini tiate the onset of referred pain to the forearm (Ness and Gebhart. 1 9 9 0 ) . S u rgery causes tissue da mage ( somatic. visceral a nd n e u ra l ) . wh ich may disrupt nociceptive a fferen t fi bres and pos topera tive pain could contri bute to the devel opment of central sensitization ( Hayes a n d Molloy. 1 9 9 7) . T hererore. p a i n mec h a n isms m i g h t i nclude a peripheral nociceptive a nd neu ropa t h i c pai n mech a n is m with a centra l componen t . These mec h a n isms are a l so applicable to the 'orthopaedic' condition. notably tbe d isc ( a nd other somatic structures) a nd the nerve root. This necessita tes more than j ust exam i ning a nd d i recti n g treatment to specillc structures in t h e neck: it is important a lso to look for the express ion of central sensitization (e. g . i ncreased receptive fiel ds and motor phenomena ) caused by i n tense stimulation of nociceptive a ffere n t fi bres . This req u i res a broader approach to p hysical exa mination a nd m a nagement. Open-hea r t surgery m ay marked ly stress the costo vertebra l j O i n ts and other anatomical structu res attach ing to the thoracic cage and cervical spine ( tor exam ple tbe scalene muscles). This m ay p redispose the cerv ical spine to muscular imbalance, but i t can also cause an i m b alance of the whole neu romuscu loskele tal syste m . This muscular imbalance can increase the stress on anatom ical structures of the cervica l and thoracic spine. The contrib u tion of muscu lar imbal ance can lead to the d e v e l o p me n t of a d isc prob lem, compression of nerves of the brach ial plexus by the scalenes muscles a n d prob l e m s i n the shoulder girdle as a resu lt of weakening or tightening of shoulder gird le tissues (such as pectora l is major tightness and rhomboid weakness) . In addition, the original anatom ica l alignment m ay not be reestablished when the sternum is s u t u red at the end of the operation. From
PAI N PREVE NTI N G
L E I S U R E ACTIV ITI E S
my own c l in ical experience. most patients undergoing open-hea r t su rgery develop pain and l i m i ted mobi lity o f one shoulder ( u su a l ly the left) and often p a i n i n the pelvic/ buttoc k area (usua lly t.h e rig h t) . The ' new' anatomical al ignment may cause a permanent i mbal a nce between pelvic, trunk a nd u p per limb structures, a nd in partic u l a r between i psi lateral l a tissi m u s dorsi and contra latera l gluteus ma x i m u s ( Vleeming et a I . , 1 9 9 7 ) . This ' new' anatomical a l ignment may have contributed to the d e ve l o p m e n t of t h e forearm pa i n . Recurrent l ower back p a i n m ay point to a postural p r o b l e m . poor ergonom ics and/or poor body mechan ics during work and other functional activities as con tribu ting factors to the onset of the recent problem. The patien t's stress d u ring work may have been a possi bl e contri buting factor to the ampli llcation o[ pain ( a nd of course to the heart problem) . However, Dan ' had no time to be sick and wanted to get rid of the problem as quickly as possible ' . A t this stage, it was rea sonable to hypothesize that stress m ay not be a sign i ll cant contributing factor: on the contrary. the fact that Dan wa nted to get weU q u ickly m ay b e a positive factor that m ay h ave e n h anced the i mprovemen t of his con d ition. This hypothesis remained to be prove n d uring the assessment and management of that d isorder. A n tico agulant therapy a nd t he fact t h a t Dan had a d isc protrusion a re contraindications to manipulation ( h igh-vel ocity low-a mpl itude thrust) , particu larly rota tory m a n ipulation that might stress the d isc m a terial and cause fu r t her protrusion. Pos itive factors rel a ted to prognosis were the facts that this was the first time Dan had su ffered an u pper limb problem, he had not received physiotherapy treatment previously a n d he was rela tively you n g . In contrast, potential negative prognostic factors included poor compliance with p hysica l exerci se ( 'he compla i ned he had no time for regu l a r exercise ' ) , the open-heart s urgery, a 2 0-year history of s tressfu l work a n d the fact t h a t h is leisu re activity (jet skiing) potential ly involved s ustained cervic a l extension , vibration a n d compression.
• C l i n ical
reason i n g co m m en tary
Some manual therapists believe that spec ific j udg about a p a tie n t s problem should b e avoided u n til the examination is completed . The answer to Question 1 n i ce ly h i g h l igh t s the breadth and depth of reaso ning that can and does occur even in t he
men ts
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'
•
I
C L I N I C A L REASO N I N G I N ACT I O N : C A S E ST U D I ES F RO M E X P E RT M A N UAL T H E RA P I STS
opening moments of a p a ti en t interview. In the midst
o f t h e p a t ie n t s problem. Here t h e c l i n ici a n has
a patient exc h ange when the clinician is focussed
rel1ected o n a broad range o f thoughts from poss ible
on listening to and understanding th e patient's
sources of the patient's symp t o ms to con tri buting
of
,
a nswers,
the
thoughts
e l ici t e d
are
often
tacit.
'
factors. pain mechanisms, preca utions a nd progno
i nitial problem
However, when questioned. as e vide n t here, expert
sis. When viewed as ' hypot heses ' , this
m a n ua l therapists are doing much more than just
for m ul a tio n is not set. rathe r it p rovid e s
l i stening. Even in these ope ning moments with the
work by which these early t houg h ts can be fu rther
patient. the c l inici a n is
b e g in n in g to fo r mu l a t e a n
impress ion o f t h e p a t ient as a pe r son a n d t h e scope
fra me
tested t h r o ug h out the p a tient interview, physical
exam i n a ti o n and on goi ng m a n agement. fu rther areas of sy mp toms revealed no other com
Area and ty p e of sym pto m s A week
a
prior t o h i s referr a l . D a n expe ri en ced a spo n ta
neous onset of a deep, sharp pain i n the dorsol a tera l aspect of the left fo rearm with pins and needles in the distal palmar aspect of the second and t hird
fingers.
p l a i n ts or symptoms, exce pt for a d u l l ache i n the lower back that had been presen t for years with n o recent
exacerbati o n . D a n ' s presenting symptoms are depi c ted in F i gure 2 4 . 1 .
He r e p o r te d that the fo rearm p a i n w a s present at res t , while the p i n s and needles ap p ea red mainly w ith extension of the cervical spine. Dan ' s postu re d u r i n g
During d aily acti vi t i es Dan repo rted
work incl uded long periods of susta i n ed ne c k l1ex i on
but c o u ld work cutting materials
.
R i di ng the Jet Ski i n volve d generally c er vic al extension with some l o wer cervical l1exion a n d mid t o upper cer
Disabil i ty and p ai n behav i o u r .
mild forearm pain while his neck was
l1exed . The movements o f the upper li mbs d u r i n g work i nc l u d ed a combina tion of shou lder horiz on tal adduc
v i cal extensio n ; v ibrations and shocks were transmit
t io n and i n te r na l rotat i o n , elbow nex i o n
ted fro m the m a chi n e while in motion . D a n c o u l d not
pron ation. and wrist and fi nger flexion of both h a n d s .
reca l l any r e cent or past trauma that could explain
The ri g ht hand w a s used t o cut t h e m a teri a l i n
the onset o f the sy mpto m s . I n de p t h question i n g for
m ovem e n t of horizontal ad d ucti o n while the left h a n d
-
Fig. 24. 1
Area a n d types of sympto m .
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,
.
fo rearm a
24 F O R EA R M PA I N P R EV E N T I N G LEI S U RE ACT I V I T I ES
stabilized the mate r i a l . If D a n attempted to ex t en d h i s neck , pain i n the forearm a n d p a r aest hesia e wo uld i m m e d ia te ly i ncrease in i n t en s i ty. When retu r n i n g to the Hexed pos i ti o n , t h e level of p a i n decreased w i t h i n a few seconds, b u t the pins and needles rema i ned for a mi n u te or two. Isolated up p e r l i mbs a n d tru n k pos i tions or m ove men ts did not a g g ravate h i s symptom s . B e lo re the problem s t ar t e d D a n u s e d to s leep i n the p ro n e - ly i n g position with his h e a d rotated to the left . A t presen t . h e could o nl y s l ee p i n t he supi ne-lying p o s i ti o n with two p i llow s a n d he woke up occasiona lly when rol l i n g over in bed as a resu l t of fo rearm p a i n . Pa i n su b s i ded q u i c k ly w he n the su pine position was re adopted . He would wa ke u p in the morning with a feeli n g of s ti ffn ess in the neck t h a t disa p pe a red a fter taking a hot showe r. In i t i a lly, Dan was worried th a t his s y m p to ms were re l a ted to h i s previous heart dis ease. His ca rd i o l og i s t had r u led this out, whi c h a llevi a te d those conce r n s . H i s m ai n concern at t h i s stage was ' to get rid of t h i s prob lem as s oo n a s p o ssi b l e ' . D a n e x p re s s e d that he did n o t h ave time to be sick and he a lso wa n ted to g e t b a c k to h is Jet S k i ri d i ng as soon as pos s i bl e . He was worried abou t the a n a to m i c a l origin of the prob lem a n d d id n o t know what the conseq uences o f a disc b u l g e were and how this could be tre a te d by physiotherapy. He was also a n xious about the possi b i lity of being paralysed.
M e d i cal and h e reditary h i story
F ig. 2 4 . 2 Computed tomography scan s h owing a lateral disc herniation a t the C6-C7 level.
I nvestigat i o n s
T h e fm di n gs from comp u ted tomog rap hy (CT) s can n in g o f the cervical s p i n e we r e i n terve r tebra l d i sc bulges at C3-C 6 , hype r tro p h i c a n d s pon dy lo t ic c h a n ges from C I-C6 w i t h n a r rowi n g o f t h e neuroforamina on the l e ft , and a l atera l disc her n i a t i o n at the C6-C 7 l evel with compression o f the s p i n a l c o rd ( F i g . 2 4 . 2 ) . Mag n etic resonance imagi n g studies were recommended by the ra d i o l og i s t; h owever, Dan was not r e fe r r e d . The n a t u re of t he d isc hern iation was not defined by t h e radiologist.
Dan u nderwe n t o pen- h e a r t su rgery fo u r years prior
to referral for p hy s i o t h er apy D u ri n g the posto perative time he experienced an e ve n t of at rial fi b ri l l a t i o n that was tre a t ed by e l ec tric shock therapy. Pa i n control dur ing the p o s to p e ra t i ve pe r i o d was adequ a te a ccord in g to Da n's r c po r t . During the months fo l low i n g car d i ac su rgery h e had two additional events of a tri a l fi bril lation trea ted in a s i m i l a r w ay. At present, his cardiac condition was bei ng m a n a ge d by med ica ti o n s, with re gular fo l low-up v i s i t s to h i s c ardi olo gi s t .
M ed i cat i o n s
presen t , D a n t o o k med ication s fo r h is h e a r t prob lems, whic h i n c lu d e d 50 m g atenolol for the con trol o f blood pr es s u re , 1 5 0 mg p ro p a fen o n e for t he con trol of the heart pace and 1 0 0 m g a s p i r i n as an a nti coag u l a n t . No medications were prescri bed by the o r thopaedic surgeon for his prese n ti n g p ro b l e m , a n d D a n d i d n o t take non- presc r i p t i o n dr u g s . At
REASO N I N G D I S C U SS I O N A N D C L I N I CAL R EASO N I N G C O M M E N TA RY
D
G iven the onset and behaviour of symptoms, what were your hypotheses regarding the dom inant pa i n mechanisms cont r i buting to his problem (s) ( physi cal and/o r psychosocial ) ?
• C l i n i c i a n 's an swe r The d o min an t pain mechanisms prese n t i n this p at i e n t app e ar ed to be a combination of p eri p h e r a l neurogenic and n oc i c ep ti ve m e c h a n i sm s . Lo o kin g s im p l i s tica l ly at
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C LI N I C A L R EAS O N I N G I N ACT I O N : C A S E STU D I E S F RO M E X P E RT M A N UA L T H E RA P I STS
the d i n ica l pre s e n ta t i o n , Dan demonstrated a c l i n i c a l
m i g h t h ave contr i b u ted to t h e m a in te n a nce or agg ra
p a t t e r n co nsiste n t w i t h compromise 0 [' the C 7 ner ve
va tio n o f h is symptoms . T h i s could be d e a l t w i th by
root. His sy mpto ms were i n c reased by exten d i n g h i s
ex p l a i n i n g the be nign cou rse a n d se l f- l i m i tin g n a t u re
neck. I t is c o m m o n t o t h i n k t b a t extension o f the neck
of t h e d iso rde r a n d e m pha s i zing the l i m ited rel e v a n c e
compromises the nerve root or d o r s a l root ga n g l i on
o f i m a g i n g s t u d ies.
i f ne ur o l og ical symp toms If this is the case, a perip h e ra l n e uroge n i c mechan ism i s l ikely t o be t h e d omi n a n t pain mecha n ism because of primary neural structure involvemen t .
mec h a n ical ly, especi a l ly a re present .
Recen tly, it h a s bee n suggested t ha t i n ll a mmatio n , a n d
II
H ad you i d e n tifi e d a ny other potentia l contributing facto rs to the onset a n d m a i n te n a n c e o f h i s activity a n d parti c i pation re str i ct i o n s a n d symptoms at th is s tage )
n o t mecha n i c a l pressure a lone. m ay b e the primary cause of nerve r oot p a i n (Hasue. 1 9 9 3 ) . I n such con d itions. p a i n is severe, ex cr u c iati ng . b u rn i n g in na ture, experience d m a i n ly a t rest and referred dis ta l ly to the re levant derma tome. D a n ' s presentation
did not appear
to have a maj or i nll a mma to ry c ompo n e n t . a l t ho u g h moderate pain w a s present at rest . His symp toms were
• C l i n i ci a n 's an swe r Severa l fa c to r s m i g h t have co n t r i b u ted to the o nset a nd ma i n ten a n ce of h is acti v i ty and p a r ticipa t i o n restric tions a nd symptoms. • Wor k i ng for 2 0 years in poor ergo nom i c co n d i tions
made wo rse by a mec h a n i c a l tri gger ( n eck extensio n ) .
( with the neck flexed a n d . asym m etr i c a l use of the
Extension of the cervical s p i ne c a n a l s o compress or
u pper l imbs against res i s ta nce) may have stressed
i m p i n ge somatic s tr uc tu res , i n c l u d i n g joint cap s u l es .
so m a tic structu res such as the C fJ-C7 d i s c . which
discs . m u scles and liga men ts . In this case, a concurrent pain mech a n is m c o u ld be a peri p h e r a l nocicep t i ve mec ha ni s m .
in turn ha d co mpressed the sp i na l nerve roo t. • Da n ' s h e a r t d i sease a n d su rgery are
likely to h ave The sympa
p l ayed a centra l role i n t h i s p r ob l em .
Al t h oug h the c l i n i c a l prese n t ation po i n ted to
a
th etic in nervation o f th e heart m ay begi n
as
high
peri ph era lly med iated p a i n ( n e u rogenic a n d noc icep
as C3 but ma i n ly comes from t he 1' 5 s e g men t : s y m
tive ) . an u nderly i n g ce ntra l pain mec ha n i sm had to be
p a t h e t i c i n nervation of the upper l im b may re a c h
c o n sidered . It i s re a s o n a b l e to think th at the i nvo l ve d
as 1'9 ( G rieve, 1 9 9 4 ) . It is known t h a t i n ll a m cardiac t i ss u e c a u se sen s i t i z a t i o n of v i s cera l n o c iceptors and a n i n crease
ne u ra l struc t u res were co mprom ised l ong before the symp toms started . The symptoms may h ave s tarted
as fa r
m a t io n a nd i sch aemia of
as a res u l t of i n ll a m ma tio n or a l ower i n g of n ocicep
of affere n t i np u t : excitation of centra l neurons
t i ve t h resho l d . Th i s means that nociceptive activ i ty
l ea d i ng to the perSistence of pain ( Ce r vero, ] 9 9 5 ) .
( w it h o u t pa i n a t thi s stage) occ ur red in the neu ral
Pa i n sens i tiv ity c an a lso b e i ncrea sed by i n tense
a n d s o m a tic str u c tu res before the symptoms started .
st i mu l a ti o n of v iscer a l structures. It might be t h a t
The vi sceral component of heart ischaemia and surgery
the n e u ral a nd s o m a t i c structures i nvo lved were
wo u l d a lso h ave been potent sources for the deve l op
a lrea dy sen sitized by prev i o us v i sceral i n p u t . The
ment o f cen tra l sensitization. The impact of neurogen ic
fact that visceral afferents converge with somatic
pain on the central nervous system is much greater than
a ITere n ts on to the centra l nervous system may partly
the i n p u t from nociceptive pain (Dub ner, 1 9 9 7 ) . The
serve as ar: exp l a n a tion for th e somatic component
primary neu ra l i nvolvem e n t and the somatic a nd v is
o f D an ' s d iso r d e r. F u r t h er more . pl a s ti c c h a nges i n
cer a l compo n e n ts of the d is ord er m ay. therefo re . h ave
the c en tra l nervo us system i n d u ced by i n te n se
en ha nced the d e velopmen t of c e n tral sen s i tiza tio n . A n a ffe c tive and cogn iti ve component may also h ave been p rese n t . However, a negative affective compon e n t d id n o t
appe a r to be d o m i n a n t in tbis case. Da n
afferen t i nput
(from the heart surgery or ischaemi a)
p l ay a r o l e i n the development a nd ma i nten ance o f hy pera lgesi a
(Cervero, 1 9 9 5 ; Zerm a n n et a I . , 1 9 9 8 ) .
• A complementary hypothesis may be a sympat hetic
expressed t h at ' h e wa n ted to get r i d of the prob l e m as
impairment ca used by the he a r t d i se a se . A bnormal
'he had n o time to be s i ck ' .
sympat h etic activity may have i nd uced t ro phic
soon as possi b l e ' a n d that
a nd other somatic str u c t u res of
H e w a s th e owner o f t h e factory a n d this p os i tio n
ch a nges at the d isc
req u ired h i m to cope w i t h the pro b lem a n d reso lve i t
the spine and ex tre m i ties throu g h co nverge n t in put
rapidly. H e was e a ge r t o g o b a c k to h is no rma l ac tiv
fr om visceral to s o m a t ic n e u rons and vice versa and
ities. In spite of t h a t , hi s perso n a l i n terpreta tion of
the occ u r rence of viscerosomatic and somatovis
the pro blem m ay h ave been a s o u rce of anxi ety a n d
cera I rell exes .
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24
F O R EA R M PAI N PREVENTI N G L E I S U R E ACTIVITI ES
a J et S k i once a week for 2-4 h o urs may h ave been a mec h a n ica l factor t h at con tribu ted to the onset of t h e pro b l e m . Vibrations a n d shocks t rans mitted fro m t h e m a c h i ne wh i l e the cervic a l s p ine i s m a i nly h e l d i n extension could potenti ally prod uce d isc da m age a nd inj ure other tissues as well . • The lower back p a i n may reOect a prev iously mech a n ically d i sadva ntaged spine. The l i k e ly origin of the lower back p a i n a p pe a r s to be a comb i natio n of poor posture and a l i g n me n t o f the whole spine a n d possibly i n a d eq u ate m uscu lar c o n tro l . I n i t i a l obser vation o r D a n ' s pos t u re suppo rted th is h ypothes i s . • D a n 's i n terpre tat i on of h is problem mi ght be another contri bu ting fa ctor. Deve loping structu re-orien ted be l iefs may lead to fe a r o f movem e n t a n d c o n tribute to the a m p l i fication and mai n tenance of the symp toms and activity or participation res tr i ct i o ns . • D a n ' s sl eeping pos i t io n appears to be importa n t as a contri b u t i n g fa c t or S leeping for a reasonable pe riod o f' t i me ma i n ly i n p r o n e ly i n g w i th t h e neck rot a te d to the left may have i nd u ce d changes in somatic tissues of the cervical s p i n e . Bony c h a n ges are l i kely to h ave occur red m a i n ly on the l eft side as t he j o i nts a n d other t issues are c o m presse d T h i s m ay gradu a l l y have caused narrowing o f the fo ra m in a , com p ro m i s i n g the p a i n -sensi tive nerve root or dors a l root gangl ion .
• R i d ing
.
.
o
owner o f a fac tory. Through a p rocess of exp l a n a tion a nd shar i n g my o w n rea so n i n g with Dan i n re l a tion to pa t h ol o g i c a l aspects of t h e prob lem , pain mec h a n i s ms a nd t h e l i m i ted va l i d i ty of i m a g i n g ll n d i ngs , he was able to d e ve l o p a re v is ed and more prod uctive u n d e r s ta n d i n g .
II
At another level of you r th in k ing would yo u ,
comment on any clu es regarding potential precau tions and contraindications to either the phys i cal examination or the management that yo u wou l d have pic ked up by this stage in the patient interview ?
• C l i n i c i a n 's an swe r T here were several points : • Oex ion of the cervical s p i n e was con t ra i n d ic a te d i n
ord er t o a v o id ca u s i n g I'u r t h e r d a m a ge t o t h e d isc and rel a ted neu ra l structu res • m a n i pu l a tio n was con tr a i n d i c ate d beca use of the p ot enti a l i nvolvement of the d i sc a n d nerve root a n d t h e use o f a n ticoag u l a nts • exercising against for c e d resistance (especi a l ly of the u pper l i m bs ) , if relev a n t , wo u l d req u i re o b t a i n i n g a p p r o v a l fro m h i s cardiolog i s t .
• C l i n i cal
What sign ificance did you place on Dan's
reaso n i ng co m m e n tary
concerns regarding the anatomical origin of h i s
The c l i n icia n ' s orga n iza t i o n of know ledge i n t o c l i n
problem and the consequences o f the dis c bulge
i c a l patterns i s clearly evident. T h e patterns a re n o t
(e.g. potential paralysis) he had been told was
l i m i t ed t o t h e u n d er ly i n g diagnosis or pat h o l ogy. Rather he speaks of evidence emerging across a
the sou rce of his symptoms?
ran ge of hy p o t h e sis categories. While n o vi c es com mon ly ma ke prem at u re conclusions
• C l i n i c i an 's an swer Dan's
based
on
one
two dom i n a n t fe a t u re s in a presentation, e x per ts should be able to recognize ev i d e n c e fo r competing or
u n d ersta n d i n g a n d concer n s re g a rd i n g the
d i a g n osis a n d potential o u tcome of paraly s is
were
l ike ly to be u n hel p fu l to his recovery. Therefore I fel t
that, while the rece n t o n s e t o f the problem was a posi t i ve prognostic fa ctor t h a t d i m i n i s h e d the IU<elihood of fixation of a b n or m al i llness behaviours, exp l a n ations regard i n g the natu ra l course of such a u s u a l ly b e n ig n problem were of pr i m a r y importance in order to avoid structu re-oriented b e l i e fs a nd fear-avoidance behav iour. Path o a n a tomy, pathone u robiology and patho biomechan ics were areas o f know ledge that p rov i d e d a basis for these expl a n atio n s . Dan was h ig h ly m o ti va ted to resolve his pro b l e m . He felt h e h a d to get back tQ m a x i m a l fu nctioni ng q u i ckly because he was the
hypotheses a n d overlapping p a t ter n s
.
This is appa r
e n t in the c l i n i c i a n ' s answers here, where the evi dence for different pain me c h a n i s m s is discussed .
The
breadth of consideration associated with
expert re a s on i n g is also well demon strated in this clinician's thoughts regarding
factors.
Ergonomic,
potential co n tri b utin g e nd o ge no us
biomechanical.
phys ica and psychosocial (cognitive and b e hav l
factors
ch ara cte r istic of expert reasoning that explanation is p rese n ted as being of primary i mp o rt a n c e and a ce n tr a l feature of the man agemen t rather than a sim p le routine 'this is your problem a n d this is what it needs ' edict. ioural)
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are aU mentioned. It is also
. '
C LI N I C A L REAS O N I N G I N ACT I O N : CAS E STU D I ES F RO M E X P E RT M A N UAL T H E RAPI STS
tE
P H Y S I C A L E X A M I N AT I O N
Obse rvation D a n ' s p o s t u r e in the u p ri g h t pos ition is depicted in F igure 2 4 . 3 . Obse r v i n g h i s posture in t h i s position revealed a med i a n ster n a l s c a r, a ' forward-head pos t u re ' . b i l a teral s houlder protraction and c o n c o m i t a n t l o w e r c e r v i c a l s p i n e flex i o n . A n a t tempt to stra i g h te n t h e who le trunk including t h e cervic a l spine, increa sed the fore a r m p a i n and p i n s a n d needles, whic h s u b s i d e d a fter a few seco n d s . Extending t h e tr u n k a l o n e did not ch ange the symptoms. D u r i n g obser vati o n , i t seemed t h a t D a n ' s willi n gness t o move t h e cervica l s p i n e was l i m i ted . A l i n e of t i g h ten i n g of the i n fra ma n d i b ular soft tissues was a lso apparent from the i n ferior part o f t h e m a nd i b le d o w n to t h e upper p a r t of t h e sternum. His l o w e r ab domi n a l area appeared slig h tly d i s tended. No s i g n s o f muscu l a r a trophy or other trophic c h a nges were o bserved.
M o b i l i ty test i n g
Cervical spi n e Extensi o n o f the cerv i c a l spi ne i n standing was a pprox i m a te ly 5 d e g rees and increased the p a i n a n d p i n s a n d need les. The movement occur red prima rly i n the u p per c e r v i c a l spine, with no movemen t obser vable
F ig. 24 . 3
Anterolateral v i ew o f t h e pati ent.
below the CS level. Pe rformi n g a gentle p a s s ive poster ior tra nslation of the lower cervical spine in the sitting posi tion increased Dan's fo rearm pain a nd paraesthesia
All other cer v i c a l reg ion mu scle length was con
S i g n i fi c a n tly. Retu r n i n g to the resting position eased
sidered norma l , except for tight splenae on t h e lert.
the symptoms within a few seco n d s . Active Ilex i o n was o f normal range, but overpressure a t the end of Ilex ion range was avoided i n the l ight of the radiologi c a l fi n d i n g s . Ro tation i n t h e Sitting position was s l i g h tly restricted to the l e ft, more so t h a n to the r i g h t , w i th no reprod u c t i o n of the symptoms . La tera l flex ion was n o t tested as this moveme n t is coupled with rotation a n d tr u e side bending of a cervical vertebra is not pos sible because of the a n atomical c o n fi g u ration of the cerv ical vertebrae (Bog d u k , 1 9 9 4 ) . Testing of rota tion i n various positions of cervical Ilexion or exten sion was n o t necessary as the symptoms were already reproduced by cer v i c a l ex tens i o n . Manu a l traction perfo r med i n sitting and i n s u p i n e lying increased D a n ' s sy mptoms . Ti g h tness of the i n frahyo id muscles
Thoracic s p i n e Rotation w a s 60 degrees t o the r i g h t
and
8 0 d eg rees
to the left. with no sy mptoms reprod uced during either moveme nt. Extension and Ilexion of the thoracic spine appeared norm a l . La tera l lTex ion was not tested.
Mobil
ity of the thoracic cage in the cepha lad direction was ex a m i n ed by a s k i n g the patient to i nspire deeply and t hen mobilizi n g the lower part of the rib c a ge u pward s. During this proced ure, resis tance could
be
fel t and
D a n reported rema rkable tenderness of the lower part of the rib cage.
L u m ba r s p i n e in
could also be fel t d ur i n g m a n u a l exa m i nation of the
Extens ion o f t h e l u m bar spine tested
trans ve rse m o b i l ization of these mu scles to the r i g h t .
(while addi n g a m anll a l postero a n terior fo rce from L4
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prone ly i n g
24
F O R EA R M PAI N P R EVENT I N G L E I S U R E ACTIVITI E S
t o S l ) w a s limited by resistance a t end r a n g e , with a
a n terior elbow regio n .
feel i n g of stiffness experienced by D a n . The movemen t
elbow exte n s i o n with wrist p a l m a r flexi o n prod u ced
was only s l i g h t ly l i m i te d a n d m a i n ly i n the lower lum bar segments. F l ex i o n was tested i n the l on g si tti n g
d iscomfo r t over the d o r s a l a s pect o f the wri s t . None of
position and l u m b a r s p i n e movemen t w a s co nsidered
same movements of the ri g h t elbow were norm a l .
A combi n ation o f pronation and
these movements reproduced D a n s symptoms. The '
normal. F i n ger to toe reach was more s i g n i ficantly reduced w i th the knees fu lly extended than with both a n kl es fu lly dorsillexed and w i t h the knees sli ghtly
Wrist
Ilexe d . N eck Ilex i o n in l o n g si ttin g did n o t h ave any
All physiological movements o f the wrist were n orm a l
effect on the overa ll movement.
a n d free of symptoms.
Sho u l d e r gi rd l e
M u s c l e co n t ro l
A l l signs a n d symptoms produced by t h e sho u l d er dur ing exami n ation were more pronounced on t he left side than on the r i g h t . The symptoms were pain in the u pper p a r t of the deltoid and s u bacromial areas, and also tightness in the ch est a n d shoulder a n teriorly. S h o u lder Ilex i o n was l i m i ted by resistance, with slight discom fort i n the s u b a cromial a re a . The left s h o u lder was more restricted than the right in both llexion and inter n a l rotation ( i n
90 deg rees abduction ) . T h e end-feel o f these movements w a s stiffer o n the left as co m p ar e d t o t he r i g h t A mild resistance could be
Tes t i n g lor rectus abd o m i n i s length prod uced a feel ing o f t ightness i n the u ppe r abdominal area. When a sked to perfo r m a n isometric contraction of trans vers u s abd o m i n i s i n the sta n d i n g positio n , i t took sev eral a t tempts before Dan could perform the correct action . Th e contracti o n could o n ly b e held for a few seconds w hi l e perfo r m i n g the movemen ts he uses at
work, fo llowing which s u b s t i t u ti o n with e x ter n a l obl ique a n d rectus overactivity was apparent.
.
fe lt d u ri n g the last 2 0 degrees o f ex ternal rotation of the left s h o u lder and at the end range of flexi o n , a n d D a n rep o r ted tigh tness in the anterior a s p e c t o f the chest. M u scle length tes t i n g revealed tight pectora l s , latissimus dorsi a n d teres maj o r ; aga in more ma rked on the left t h a n on the right. fnferior and a n teropos terior accessory movements o f t h e left gle n o h u meral j o i n t tested at the end ra n ge of Ilex ion we re also more restricted on the l e ft than o n the r i g h t . S u bacromial p a i n was reproduced w i t h the i n ferior gl ide performed a lso at th e end of the llex i o n ra nge. Other j o i nt p l ay movemen ts of t he shoul d er were n orma l, with no symptoms re prod uced d u r i ng these movemen t s .
N e u ro l ogical exam i n ati o n Reduced muscle s t re n g t h o f t h e biceps a n d triceps m u scles and a decreased triceps reflex were fou n d o n t h e left s i d e . N o cord signs were detected d u r i n g exami nati o n . S e n s ation w a s c o n s i dered normal.
N e u rodynam i c tests Upper lim b ne u rodynamic test 1 (medial1 nerve bias) , T h i s u p per l i m b neurody n a m i c test (ULNT) did not reprod u ce D a n ' s symptoms . However, a l l compo n e n ts s h owed restricted motion on t h e left side compared w i th the right side, w i th a d u l l a c h e felt fro m the wrist up to the axi l l ary reg i o n . T h i s ache
E l bow regi on
was n o t present o n testi n g the ri g h t side.
Both active and passive nex i o n move ments of t h e left elbow were normal . There was a limi tation of
5 degrees a t the end of extension r a n ge with a ' lea thery ' end feel . D a n reported a d u l l a c h e a n d a fee l i n g o f t i g h t ness i n the anterior aspect of the elbow d u r i n g this moveme n t . S u p i n a tio n was s l i g h tly l i m i ted at e n d range, as was p ro n a tio n , b u t no symptoms were pro voked d u ri n g either movement. A combi n a t i o n of supination a n d el bow ex tens ion revealed an increase i n resista nce and an i ncrease o f the d u l l ache i n the
Uppe r limb n e u rodYl1amic test 2 (radial nerve bias) , Excep t for a feeling of tigh tness i n the la t e r a l aspect and dorsum o f the upper a r m , forearm a n d wrist. no other symptoms could be reproduced and the r a n ge o f movement was normal o n the r i g h t s i d e . This fee l i n g of tightness was more marked o n the l e ft side, with a slight r es t ric t i o n of range evident. Slump test,
No S i gn i fi c a n t symptoms cou ld
reprodu ced w it h the slump test.
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be
C L I N I C A L REASO N I N G I N ACT I O N : C A S E STU D I E S F RO M E X P E RT M A N UAL T H E R A P I STS
Pal pati o n
P ressu re o n the l e ft forearm ski n a nd m u scles
A l a rge area o f a l l ody n i a ( i . e . p a i n from
a
stimulus t h a t
in the sym ptomatic a rea prod uced h ype r a l ges i a ( a n
d o e s no t n o r m a l ly provoke pa i n ) w a s detected w i th
i ncre ased response to
fi r m p a l p a ti on a n d m o b i lization or the s k i n over the
pa i nfu l) . On the r i g h t forearm. a U odyn i a was prese n t
posterior cervical area a nd the left side of the b a ck down
i n a n identical a rea a s t he left fo rea rm ( as t h e pa tient
a
s t i m u l u s t h a t i s no rm a lly
to the lu m b a r s p i n e . Skin m o b i l i ty was a lso restric ted .
had not re p o r t e d a ny sy m p tom s in t he right fo rearm.
es pec i a lly in the l e ft cer v i c a l and posterior s h o u lder
t h e resp o n se to p a l p a tio n was defi ned as · a lJody n i a · ) .
g i rd l e a r e a . The s ki n i n t h i s a re a was th ickened . Inter
S i g n i fica n t tende rness was al so fou n d over the deltoid
estingly. p a i n and pi ns and needles i n the forearm could
re g i o n .
be re p ro d u ced wh ile p a l pa t i ng a nd m o b i l i zi n g the
a nd esp ec i a l ly i n the posterior part or t h e m uscl e .
more o n t h e l eft s i d e than o n the r i g h t side.
nerve in
radial groove forearm and with the rig h t
ski n of all t h e above areas a n d a l so wi th no n - sp ecific
Pa lp a t i o n of the l e ft rad i a l
p re ss u r es a pp l ied to the deep s tru ctu re s of t h e cer
p rod uc e d pa ra es th es i a e in the do r s al
the
v i c a l a n d t h o racic regio n s . Dan h ad not re por ted a ny
wri st . T h i s res p o n s e was not e l i c i ted
sym p toms i n these areas prior to pa l p ati o n .
ra d i a l ne r ve . Pa l p a tio n or the a b d o mi n a l a rea a n d the
Tight b a n d s of musc les on the l eft side cou l d be fe l t d u ri n g pa lp a ti o n of t h e deep m u sc l e s o f th e cervic a l
a n ter i o r c he s t de tec ted l arge a reas of a l lo dy n i a . p a r
ticu l a r ly ov e r the su rg ica l scar a nd t he u ppe r abdom
spi ne. w i t h re m ark ab le tende rness e l icited a nd fo re
i n a l are a . A m a rked restric tion of mo b i l i ty o f the skin
arm p a i n and pi ns a n d needles rep ro d uced . The u p per
i n t h es e a reas was a lso detected . D u ring pa lp a tio n and
trapezius m u s c l e on the l e ft was t h i cke ned a n d tender.
m o b i lization of rectus a b d o m i n i s . dysaesthetic p a i n
Deep pa lp ati o n of the b o ny s tr uc tu r es s howed marked
( i . e . a pai n fu l . u n p leasa n t abnorm a l sen satio n ) was
thic ke n i n g over the a r tic u l a r p i l l a r. most n ot a bly a t
prod uced in th e left forearm a n d w ri st regi o n s . w i t h
the C 6 level o n at the
� I j D
C5
the
left s i d e . a nd to
a
l esser degree
a n d C7 levels.
a n exp a n s i o n or t h e pins a nd need les a rea to t he wh o le u pp er l i m b and h a n d .
REASO N I N G D I SC U S S I O N A N D C L I N I CAL REASO N I N G C O M M E N TA RY
within a C7
D e s p ite the e m e rging patte rn of a C7 n e rve
numerous presentations are p oss i ble
root c o m p ro m i s e from the exam i n ation of the
root sy n dro me d i a g n os i s . For t h e m a n u a l therapis t ' s
s p i n e a n d s h o u l d e r, you sti l l p roceeded to carry
ma nage m e n t to be s u c cessru l . the i r u nd er s ta n d i ng
nerve
o u t q u i te an exte n s ive physical exa m i n ation
must be broader and i n clude the ru l l biopsychosoc ial
of other a reas at the fi rst v i s i t. C o u l d yo u
p ictu re . The picture emerging for t h is p at ien t was one
c o m m e n t on yo u r reaso n i ng fo r th i s ?
o f a cen tra l l y m e d i a t ed p a in m ech a n ism u n d er l y i n g the d iso rde r. w i th path okinesiol ogy prese n t as a res u lt of poor body mech a n ics d u ring work a n d possi b ly pre
• C l i n i c i a n 's answe r
d i sposed by h is previous open-heart su rgery.
In s p i te or an e m erg in g clinical pattern of C 7 n e r ve
Viscera l pathologies suc h as heart ischaemia cause
root syn d ro m e . the hy po thesis put forward duri ng d a ta
sens itization of p r i m a ry afferents . The n ervous system
c o l lection ( i n terview a n d p h ysi c a l exami n a ti o n ) wa s
and tis sue i nj ury p a i n from surgery or n e rve root com
t h a t t h i s c l i n i c a l presen tation is the ' fi n a l common
preSSion may lead to a centr a l ly mediated p a i n c h ar
p athway ' of a mucb more comp lex disorder. It has to
a cte rized by ce n t ra l sensitiza t i o n . d isinhibition a nd
be n o ted t h at C7 nerve root sy nd ro me i s a medica l
structural reo r ga n iz at i on in t h e cen tral nervous system
d ia g nosis or a m ed ic al clinical pa ttern t h a t does no t
( Woolr et a l . . 1 9 9 8 ) . P ur t h ermore. pain in general. and
esse n ti a l ly contain t h e same c h u n k s of i n forma tion
more par tic u la rly fol l o w i n g myoca rdi a l isch aemia,
as a m a n u a l t h erapy c l i n i c a l pa ttern . A l t h o u g h both
su rger y a nd i r ri t a t i o n of the nerve root and other
desc riptions s ho u l d h ave in common the pa th o logic aJ
somatic str uctures . may be accom pa n i ed by a who le
b ackgro un d
body reacti o n ( Wall. 1 9 9 9 ) . These re actions may
and
cer v i c a l
spi ne
patho m ech a n ics .
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i nc l ude p h e n omen a s u c h as muscu l ar c o n t r a c t i o n i n m a ny p a r ts o f t h e b o d y a n d c h a n g es i n blood n o w a n d hormones i n tissues of t he bo dy. T h i s resembles t he p i c t u re fo u nd in c o m p lex r e gion a l p a i n sy n d r o m e ( type
I)
t h at h as re c e n t l y been cons idered a n e u ro
(J an i g. 2 0C H ) . The me c h a n i ca l compon ent o f heart s u rge r y is a no t her factor that may h ave a l tered ce r v i c a l spi ne mec h a n i cs and p ost u re . The cer v i c a l s p i n e i s the most m o b i l e region o f the e n t ire sp i ne a n d . c o n sequent l y. m ay be partic u larly v u l n er a bl e to a l te red pos t u r a l a l i g n me n t a n d abnorma l b i o mec h anics of o t her parts of the body. Wo r k e rgo n o m ics m ay h ave a lso led to t h e fi x a t i o n of ab e r ra n t movement p a tte r n s . which had fa c i l i t a ted t he deve l o pment 0 1' ' w h o l e b o dy ' abn o rm a l me c h a n ics . The adoption of a trad i t i o n a l med i c a l model wo u l d l ogi c a l d i se as e
res u l t i n a d i a gnosis of C 7 nerve root sy n d ro m e ( i . e . a · ti s s u e- bas ed · approa c h ) . Treat m e n t wo u l d . therefore. aim a t re d u ci n g pressu re o r i n l1 a mm a t i on of th e nerve roo t . thereby a l lev i a ti n g the signs and sympto m s . T h i s wou l d e n d c l i nica l i n te r v e n ti on . However. t h i s mo d el m a y not be a pp l i c a b le to m a n y musculoske l e ta l con ditions i n genera l an d more par t i c u l a dy to t h i s s i t u a tion . The i mp a ct o r t h e p a t i e n t ' s med i c a l histo ry. h i s occupa tion a nd t h e i n rtuences o f tissue i nj u ry ( ne u r al and somatic) n ecessitate an a ltern a tive model for d i a g nosis a n d m a nageme n t . This mo de l e m p has iz es the n e u robio logic a l a spec t o f the c l i n ic a l p r o b l e m a n d the fa ct that a l l parts o f the movement sy s te m are ana to m i c a lly and fu n c t i on al ly related . Nevertheless. this model does not n ega te the consideration of specific mechan ica l c a u ses and a n a t o m i c al s o u rces respo ns ible fo r the p a tie n t ' s p hysc i c a l i mpairments and symptom s . In t h e l i gh t of the a bove appro a c h . i t w a s e xpec ted tha t c h a n ges i n m a ny parts of the m o ve m en t system wo u l d be p res e n t and an ex ten sive ex a m i n a ti o n to prove or negate these theories a n d hypo t h es e s wo u ld be j ustified. It w a s consid ered that u n ders t a n d i n g , from the sta r t . the presen tation in t erms of pain n e u ro biology a nd fu nctiona l bio mechanics was of primary i m p o r ta nce a n d wo ul d hav e a s i g n i fi c an t i m pact o n the man a gem e n t context of t h i s cl i nical disorder.
D
Ple ase discuss you r ratio n a l e for unde rta king
F O R EARM PA I N P R EV E NTI N G L E I S U R E ACT I V I T I ES
• C l i n i c ian's a n swe r The ratio n a l e behind th e palpa tion ex a m i n at i o n was
mec h a n ica l and neurobiologica l . Mec h a n ica lly. skin m o bi l i ty i s of ex t reme impor tance to overa l l m o b i l i t y and fu nction as i t is c o n t i n u o u s to the deepest m u cos ae ( W i l l i a ms and War w i c k , 1 9 8 0 ) . Co n s id e r i n g the ski n as a continuu m . it may h ave ad hered to s u b c u taneous tissues d u ri n g healing an d rep a i r processes fo l l o w ing s u r gery. F l u i d s ( e . g . sero m a ) prese n t a t the s i te of operation may i n fi l tr a te t h r oug h s ubcutaneous tissues to d is t a n t s i tes ( s u c h a s t. h e l u m b a r re g i o n ) . as i s often see n , fo r ex a mp l e . i n fractmes of the h u me r u s where haematoma is observed i n t h e forearm a n d h a n d . The m ed i a n s te r n o tomy sc a r may h ave i n fl ue n c ed movement of the t ho rac ic spine. ce rvica l s p i ne, s h o u l d e r g i r d le a n d u p per l i mbs. F o r i ns ta nc e. t h e sc a r may h a ve c o n t r i b u t e d to restricted cervica l extension a n d shoul der n ex i o n/abduction . T he s u pe rfi c i a l a b d o m i n a l m u s c les . espec i a l ly rectus abdo m i n i s . a ppea r e d to be overactive. po ss i b l y re l1ect ing a l e a r n e d ac t i v a t i o n p a tt e r n seco n d a ry to p o s t o p e ra t i ve g u ardi ng . Con tinued overactiv a t i o n of the supe r fic i a l abd o m i n a l m u sc les at the expense of the d ee per s t ab i l i ze r s ( s uch a s transversus abdo m i n i s ) ( R i c h a rd s o n et a I . , 1 9 9 9 ) is a l so o ften associated w i th l e a r n ed or m a la d ap ti ve cer v i c a l postures and m o ve m e n t pa tter ns d o m i n a ted by lower cer v i c al fl ex i o n a n d upper cer v ic a l exte n s io n . T b i s m a y overload lower c e r v i c a l segm ents and c o n t r i b u te to the d eve lopment o f d i s o rders o r to the aggravation of a l re a dy ex is ti n g pa tho l o g ies . Thoracic segments ( T l -T 1 2 ) th a t h ave converge n t i n p u t from the viscera innervate the c h est and a b dome n ( for exa m ple the h e a r t is innervated by T S -T 6 ) . T h i s c o nvergen t i n p u t m a y c a u s e s e gme n ta l fac i l itatio n . wh ich renders the target tissues a n d organs sensitive to pa i n . A sim i l ar logic b a sed upon neurophys i o l o g i ca l p ri n c i p l es can also be fo u n d i n t h e tech n iq u e of con n e c tive tissue m a n ipu l a t i o n ( Eb n e r, 1 9 8 5 ) . w here by the a i m of the tech n i que is to i n n u en ce the fu nction o f visceral organs v i a specific co n ne ctive t i ssue z o n e s loca ted in the b ack o f t he tr u n k a re a . O n e of th e fe atu res o f ce n tra l ly med iated pa i n i s i ncreased recep tive fields. T h e recep tive fie l d s m ay
A
s u ch an extensive palpatory examination with
spread se g men t a lly a n d a lso mu ltisegmenta l ly.
this patient, particula rly why you thought it was
sive nociceptive i n p u t fro m the viscera or from somatic
mas
important to palpate and mobilize the s kin and
o r neural tissue may c o n trib ute to a ce n t r a l ly medi
muscular tis s u e in regions such as the chest and
a ted p ai n . Therefore, an ex te nsive pa lp a t i o n exam i n
abdome n .
a ti on was j u s t i fied i n order to detect poss i ble a reas o f Copyrighted Material
C LI N I CA L REAS O N I N G I N ACTI O N : CASE STU D I ES F R O M E X P E RT M A N UAL T H E RA P I STS
tenderness ( i . e. a l lody n i a and hyperalgesia), which are
and symptom s . This sensi tive physical impai r ment
fe a t u res o f central sensi tizati o n . In add ition , s tress
consti tuted a peripheral mechan ism fo r the symptoms.
fro m myocardial in fa rction and cardiac s u rgery pro
Therefore. it was hy pothesized that a centra I ly med i ated
d u ces a d rena l i n e a nd n o radrena l i ne and activates the
p a i n was prese n t in combination
hy potha lamic-pituitary-adrenal axis to i n crease cor
med i a ted p a i n .
with
a
peripher a l ly
ticosteroi d s . The neurohormones cause a n i n crease
Regardi ng other i nvolved structu res a n d mech
in sympathetic activi ty, which m ay, i n turn, affect tis
a nisms. it was d emonstrated during the physical
sue trophism . Tissues can become tight and d emon
exa mination that a l tered body mecha n ics was of sig
strate poor compliance with mec h a n ical l o a d i n g as
n i ficance. The restricted movements of the l e ft upper
a result o f trop h i c changes. Tissues may a lso become
limb. the limi ted range of motion of the thorax to the
sensitive to p a i n .
right. the u pper abdo m i n al tightness and the lower
A not her exp lanation m a y be fo und i n t h e i n nerv
abd o m i n a l we akness were aU p a r t of a ge neral phys
ation of latissimus dorsi. Latissimus dorsi is in nerva ted
i c a l impai rment, probably caused by poor body mec h
p artly by the
C7 segment. Al though i t is h a rd to d i f
anics during
daily activ ities and by the cardiac su rgery.
fere nti ate c l i n i c a lly betwee n l u mbar struc t ures a n d
These path o a n atom i c a l aspects or t h e pro b l e m may
l a t i ss i m us d o r s i . i t is poss i b le t h a t the i n iti a l invo l ve
a l so have i m p a i red neu ral tissu e.
C7 segment m ay h ave co ntribu ted to the
Pa radox i c a l ly. t he responses obtai ned duri n g the
sensitivity de tected at the l u m b a r r e g i o n wi t h p a l pa
upper l i m b neurodynamic tests d id not show a major
ment of t h e
It was hy pothesized that i f a
t i o n . M u scles c o n t a i n nociceptors a n d c a n be a poten
neu roge n ic component .
tial sou rce of pain (Mense, 1 9 9 3 ) .
n e rve root was i nvo lved in t h i s syndrome it was likely that the ULNTs should reproduce the symptoms. Elvey ( 1 9 9 8 ) has su ggested that neural tissue treatment
Please c o m m e n t o n h ow the p hysical exam i n ati o n fi n d i ngs c o n tr i b uted to your u n d e rs ta n d i ng of th i s pati ent's pro b l e m ( s ) , i d e n ti fy i n g, w h e re p o s s i b l e , s p ec i fi c hypoth e ses that were or were n ot s u p p o rted by p a rti c u l a r fi n d i ngs.
shou ld be consid ered when a neu roge n ic patho logy is present. However. it i s still not clear yet wh at the fea tures of sllch a neu rogenic pathology are (Elvey 1 9 9 8 ) . Butler ( 1 9 9 8 . 2 0 0 0 ) st ates t h a t pro d u C i n g or repro d u c i n g symptoms d u ring a n ULNT s i mply means that the specific movemen t is sensitive. This sensi tivity may be a result of peri pheral as wel l as central ne rvous
• C l i n i cian's an swe r .
system i n p u t .
It was ex pected t h a t the ULNTs would
A maj or observation t h a t c a n be drawn from the
rel iably reproduce Dan's symptoms if there were
p hysical ex amination i s that the forearm symptoms
m aj o r neural i nvo lvement. The maj o r filleti ng in both
a
It wo u ld not
h a d m u l tiple sources. P hys ical exa m i n a ti o n find i n gs
ULNTs was a l i m i tation of movement.
i n d i c a te the i n adequ acy of the med ical model fo r
be plausible to cor relate this l imitation of movement
d i agnosis a n d treatme n t in this patient. Searc h i n g for
so lely with neural structu re s . Therefore, the fi ndings
a single s o u rce to the symptoms wo u ld h ave been a n
of the ULNTs did not s u p p o r t the hy pothesis of a l tered
error i n s p i te of a n obvious c l i n i c a l presentation of
neurod y n a mics. The response o b t a i ned i n applying
nerve root sy ndro me. W h at could expl ain the a J lody
the ULNT (radial n e rve) to the left side poi n ted to a tis
nia in the right forearm? What i s the b a s i s for hyper
sue res tric tion component ( n o t necess arily neu ral in
a lgesi a and reproduction of the forearm symptoms by
o rigi n) . which may have developed as a res ult of sur
stretc h i n g the s k i n of the back? What could acc o u n t
gery or from sympathetic dys fu nction lead ing to
for t h e i ncrea sed sensitivity of the r a d i a l nerve t o p a l
poor trophic condition of these tissues . A similar
p a tlo n ? Symptomatic responses obtai ned during the
r a tiona le may be appl ied to the res ponse to the slump
physical ex amination p O i n ted to maj o r i nvo lveme n t
test . Nevertheless . i t i s possible that conven tional
of t h e central n ervous system . If there were a s i n gle
ULNTs were not s u ffic i e n t to reproduce neural symp
a
a n atomical so urce to the symp toms, stretc h i n g the
toms . In a d d i t i o n , consider i n g that this disorder was
would not reproduce the
mostly non-inflammatory. mechanosensi tivity was
abd omin a l sk i n . for example,
forearm symptom s . Never theless. abnormal mechan
rela tive ly low.
C 6-C 7 functional s p i n al u n it was clea rly
Traction increased the symptoms when performed in
primarily responsible for D a n ' s fu nctio n a l problems
the sitting and the supine-lying positions. A generally
ics of the
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24
a c c e p te d notion i s that, i n the presence of nerve root
FO REARM PA I N PREVENT I N G L E I S U R E ACTIVITI ES
compres s i o n in the cerv ica l spine (or lumbar spin e ) .
• C l i n i cal
trac tion s h o u l d relieve t h e press u re o n t h e nerve a n d
The key feature of expert reasoning evident in the
reason i ng co m m e ntary
a s a res u l t symptoms should be ea sed . T h i s assu mp
philosophy expressed in this answer is the recognition
tion may be wrong fo r sever a l re a s o n s . F i r s t . traction
of the inter-relationship of the body 's systems (i.e.
has l i ttle e ffec t on ve rtebral separation in the lwnbar
neural. articular. myofascial. visceral and endocrine ) .
1 9 9 7) . It is possible that similar mec h a n ic s are ap p l i c a bl e to t h e cervic a l spine. Sec ond ly. t h e nerve root is con nected to the verte bra a n d
The significance of this appreciation for t h e clinical
longitud i n a l movement o f t h e ve rtebra may a l so aJTect
symptoms. must be entertained with
the nerve. It should also be noted that i n tr a d u r a l con
ation of other components of the problem such as
spine
(Bogd u k .
reasoning used by
manual
therapiSts is that specific
foci of reasoning. such as the source of the patient's
full
consider
neclions exist be tween the d o rsal roo t l ets of C S . C6
pain mechanisms ( see Ch .
a n d C7 (Ta n a k a et a l . . 2 0 ( 0 ) .
of th e likelihood of central pain mechanisms con
m i g ht be
a
an
a n a to m i c a l fact that
source of c o n fu s i on in the interpreta tion of
clinical fi n d ings. F i n a l ly. moveme n t of sensitive somatic
1 ). Wi th o u t consideration
tributing to this patient's presentation. including t he probability of fa lse-positive signs of somatic ancl neu
tissues or t e n s i o n i n g of the d ura m a t e r in t he cervica l
rogeniC impairmen t in multiple areas. the less-experi
spine m ay re produce the s ym p t om s . Tra c t i o n as a
enced source-focussed therapist would either proceed
c l inical t e s t t here fore. does not support nor negate
to treat each region as
the i nvo lveme n t o f nerve root patho logy.
write the patient off as being ' psychogenic ' . Simi lar ly
.
a
separate problem or si mply .
The I1 n d i n gs of the ne uro logic a l ex a m i n a tion may
h ave d i fferen t i n terpreta tion s . Wea k ness of the tri ceps and biceps muscles cou l d be exp lained by com promise of the C 6-C 7 nerve root. However. we akness
n here has not reached the premature j udgment of labelling the whole presentation as the
c lin i c i a
being
'central'
and. therefore, potentially not appro
priate for hands-on therapy. Rather. his hypotheses
o f these muscles can also be ex plained by the phe
remain open . with recognition that perip her al and
nomenon of pe r i p h e r a l pseudoparesis. i nvolv ing a
central pathological pain mechanisms can coexist.
c e n tra l nervo u s system inhibition of the muscles as a
Also evident in the clinicia n ' s reasoning is his abi l i ty
result of o ste o a r tic u l a r or neural pathology (Jand a ,
and willingn ess to c o n sid e r d i fferent interpre ta
1 9 8 8 ) . Consequen tly. t h e neurologi c a l examination
tions for the c l inic a l fin d ings . For example. h e dis
does not defi n i tively s u pport o r n e ga te n er ve root
c ussed clinical (experience-based) and biomedical
p a t h o l ogy. The palpation exa m i n a tion revealed interesti n g fi n d i ngs t hat negated t h e l i ke l i hood o f a single source
esis, which at this stage was not con firmed given th e
and mec h a n is m for the symptom s . The i ncreased
ign ore findings that do not fit with a likely exp l a na
sensitivity o f many tissues a n d the reprodu ction of
tion (e. g . effect of traction
the symptoms from remote structu res supports the hypothesis o f a cen tral nervou s system contribution to the sympto m s . This contribution was ex pressed in the ex pansion of sensitivity throughout the muscu loskeletal system and i n the trophic cha nges i n d uced by sympathetic d y s fun ction or the healing process
compression) nor does he over emp h asize findings
fo llow ing surgery.
(res e arc h b ased) evidence for -
a
neurogenic hy poth
competing interpretations he outlined. He d oes not
when
that support this part i c ul ar explanation
l ogical) .
cons i d e r i n g nerve
(e.g. neuro
Such open-minded . critica l and flexible
thinking typifies a n expert. F u r t h er differentiation of t he relative contribution of each mech a n ism l:m d the di fferent sources bein g considered can only come from strategic a n d reflective intervention .
[3';m'f'4" '''''At the end of the examin ation. Dan was given a d etailed
ex p l a n a tion of the assessment fi n d ings and their clin ical s i g n ifica nce. T h e relevant cli n ical hypotheses
regard i n g the possible sourc e s . causes. p a i n mech a n i s m s and biomec h a n i c a l issues were o u tli ned. The general manageme n t p l a n a n d estima ted tre a tme nt o u tcomes were also d iscussed .
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I
C L I N I CA L R EAS O N I N G I N ACTI O N : C A S E STU D I ES F RO M E X P E RT M A N UAL T H E R API STS
REASO N I N G D I SC U S S I O N A N D C L I N I CA L R EASO N I N G C O M M E N TA RY
o
Pati e n t u n d ersta n d i ng is clearly i m p orta n t to
i m p o r t a n c e of ergo n o m i c fa ctors and pain mec h a n
yo u r m a n age m e n t. C o u l d you c o m m e n t on th i s
isms
i n g e n e ral a n d a l s o i ts specifi c re l evance t o t h i s
not
pati e n t ? H ow d o yo u b a l a n c e t h e pati e n t's d es i re
I n h is case. si nce he w a s ab l e to concep t u a l i z e a nd
( in p a r t i c u l a r t he c e n t r a l componen t ) . D a n was h ard to conv i n ce. as he trusted my ex p l a n a t i o n s .
to have a ' p hys i c a l ' e x p l a n a t i o n fo r h i s p ro b l e m
accept t h i s expl a n a t i o n . h i s be l i e fs d id n o t i n terfere
w i t h the r i s k of ove rm e d i ca l i z i ng a n d promoting
w i t h h i s coope r a t i o n d ur i n g m a n ageme n t .
path o l ogy-foc u s s e d be l i efs ?
• C l i n i c i a n 's
• C l i n i cal
answe r
As d iscussed
reason i n g c o m m entary
in Ch apter 1 . n a r ra tive reas )I1 i o g t h a t
The p a t ie n t s own k n owled ge. beliefs a n d reaso n i n g a re a key fa c t o r i n my manage m e n t . D a n w a s con
a i m s to u n dersta nd the ind ivid u a l 's ' p a i n or i l l ness ' experience l ead s to co m m u n icat ive m a n a gemen t .
cerned by the fact t h a t he had a d isc compres s i n g h i s
I n communica t i ve m a nagemen t . a s i l l u s t ra t ed i n
nerve. T h e p i c t u re he h a d i n h i s m i nd ( o n t h e basis o f
t h i s casco
view i n g C T fi nd i n gs) wa s t h a t a m a s s wa s compress i n g
the patie n t u n derst a D d their act ivity/pa r t ici pation
t h e nerve a n d c a u s i n g h i s symptoms and fu n c t i o n a l
restrict ions. phy s ic a l
pro b lems
i n g patients to change their perspectives when (-hese
'
.
I t w a s i m p o r ta n t t o b road en h i s u nder
the therapist works c o l l abora t i vely t o help impairments and pa i n . Assist
counterprod uc to their recovery req u i res exploring the basis of
s t a n d i n g of the problem by e l aborati ng about t h e
h ave been j udged to be u n h elpfu l or
mechanisms of his p hy sic al i m pairments a n d pa i n .
tive
by s u pp ly i n g ' ne w ' knowledge, a n d b y a ssi sti n g h im
tbose perspectives and then providing the patient
to a d op t a new perspec tive about t h e va l i dity of t h i s
with new i n/ormation to i mprove t heir u nderstand
informa tion . The a im w a s to draw his attention toward s
ing of their problems and pain stale. When slIccess
factors o t h e r t h a n the d isc t h at were respo nsible [or uted to h i s o n go i n g p r ob l e m . My ex p l a n a ti on focussed
ful . the patient is then able to t ra n s form their previously u n help/u l perspec tive to a new way of see i n g and u nderstanding. idea lly w i t h better apprecia
o n the lirlli ted v a l i d i ty of i m a g i n g fi n d i n g s a nd on the
tion of their role i n the management req u i red .
the onset of the d i sorder a n d that m i g h t have con tri b
• Treat m e n t
• Treat m e n t 2
1
The first treatment i n c l u d ed a postero a n terior mobil
D a n repor t e d no treatment soreness fo l l ow i n g the nrst
ization of the d eep posterior cer v i c al muscles a nd skin
trea tmen t and a signi ficant d e c rease in the i n ten sity
2 4 h ou r s . Exte n sion
m o b i liza t i o n to the posterior thoracic and l u m b a r
of th e symptoms a fter
areas in t h e s upi n e l y i n g pos i t i o n . D u r i n g trea tmen t .
v i c a l spine rema i n ed at 1 0 degrees , as it was a t the end
-
pain a n d
of the cer
p in s a n d needles sensation were reprod uced
of treatme n t 1 . The second treatment focussed ma inly
i n the left fo rearm when using b o t h tec h n iq u e s .
on i m p rov i n g posterior tra n s l a t i o n at the C 6-C 7 l evel
a
O n reassessme n t . a n i mprovemen t of ap proxim ate ly
i n the s itti ng positio n while provok ing the symptoms
5 deg r ees of active cervical s p i n e extension was
to a tol er able level . The s y mp to ms su bs ided im med i
ach ieved . Neurol ogi c a l exam i n a t i o n and p alpati on
ately when the tech nique was cea sed .
I1 n d i n g s rema ined u ncha nged Other ph y sica l exa mi n .
a t i o n fi nd ings were n o t reassessed a t this stage as t h e neu rologic a l
exam i n ation
and
p a l p a tion
fi n d i n gs
.
Posterior tra n s l a t i o n is o ne of the moveme n ts of a cerv i c a l ve rtebra ( t he
occurri n g d uring ex te ns i on
o t her movements be i n g posterior S a g i tt a l rotation
were cons idered of primary i mpor ta nce in rel a t i o n to
and compressi on of the posterior clements ) . The tec h
pain and neural compromise Dan was advised to avoid
niq ue u sed t o improve posterior tra n s la t i on i n vol ved
.
and to mod i fy
fixation of the C 7 vertebra w h i l e exten d i ng the l ower
h i s position d u r i n g wo r k . s u c h as s i tting i n s tead of
cerv ica l spine and emphasizi n g the tra n s lation com
sta n d i ng. No s pec i fic exerc ises were g ive n a t
ponen t of C6. The aim of this tech n iqu e was to restore
work i n g with s us ta i n ed neck l1ex i o n
this stage.
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24 F O R EA R M PA I N P R EV E N T I N G L E I S U R E ACT I V I T I E S
norm a l extension, as restriction or this movemen t was clea rly con tribu ti n g to Dan's symptoms. Because of the l i m i ted inlla mmatory component of the d isorder. it was considered reasonable to reproduce the symptoms to a cer t a i n extent without risking aggravating the con d i tion . The sort tissue tec hnique appl ied to the left cer v ica l deep muscles was combi ned with the pos terior tra n s lation mo b i l ization o r the C 6-C 7 a r ticu lation. Active neck retraction was also added simultaneously i n order to e n h a n ce th e tra nslation movemen t of the lower cervical segmen ts and to rac ilitate contraction of the d eep a n terior cervical muscles and lower cer v ical extensors. wh i l e lengthe n i n g the m i d d l e cer v ical ex tensors. This tec h n ique yielded 3 0 deg rees o f cer vical ex tensio n . w i th forearm symptoms reproduced at end range . The s k in-stretc h i n g technique was a lso repeated . y ield i n g a decrease in the i n tensity or the rorearm symptoms at end range or cerv i c a l extensi o n . Fol low i ng these tec hniques. t h e range o r movement o f both ULNTs was improved. with symptom reproduc tion rema i n ing the same. Neu rological ex amination find ings were still unchan ged . Dan was ad vised to sta r t neck retracLion exercises while mild ly re prod uc ing the sy mptoms a nd susta i n i n g the moveme nt for ap proximately 10 seconds for 1 0 re petitions twice a d ay.
• Treatment 3 Dan repor ted a significant ru nctional and symptomatic im provement. S i nce the last treatment. h e had not felt any p a i n or other symptoms in the forea rm a n d h a nd. However. he repor ted a dull p a i n in the la teral upper third of the lert arm at rest. This pain had not been repor ted previously. O n examination . cervical ex ten sion range of movement was maintai ned , while symp toms i n the upper arm, rorearm and h a n d were reproduced at end range or cervical extensio n . The arm pain remained u n c h a nged with cervical extension . The posterior translation movement of the C 6-C 7 level was al most fu l l range, w i th mild resista nce evident a t end range. Allodynia w a s red uced in area t o t h e left upper quarter of the thoracic region and was associ ated with reproduction o f pins and needles in the upper arm, forearm and h a n d . Initially, al lodynia had been present over the wh ole o r Dan ' s back o n the left side but had only reproduced the forearm pain and pins and need les . The treatment techniques used i n t h e second treat ment were repeated . O n reassessment, a dull ache
in the forearm was reproduced w i th active fu l l -range cervical extension without overpressure. D a n was advised to continue cerv ical retraction exercises. As pelvic a nd l u mbar spine al ignment was considered to be a contributi n g factor to Dan ' s problem. stra i g h t leg ra i se and lumbar extension exercises were also a d d ed i n order to e n h ance postural a l i gnment.
• Treat m e n ts 4 to 6 Since the previous treatment. Dan had not relt any pain or paraesthesiae i n the forearm a n d h and. However, a d u l l ache was present in the l atera l u pper t h i rd of the forearm and lower t h i rd o f t h e upper arm. Th is ache was not in itially present. Cervical extension range of movement was m a i n ta i ned , with the symptoms in the upper a r m , forearm and hand sti l l reproduced at the end range. The posterior translation movemen t o f C6-C 7 w a s full range, with normal resistance detected . A l lody nia remained red uced in the left u pper quarter o f the thoracic a re a . with reproduction of pins and needles i n the u pper a r m , fo rearm and h a nd during skin mobi lizatio n . T h e t herapeutic tec h niques used d uring treatments 4 to 6 i ncluded stretching o r the sternohyoid muscles, performed with s i multaneous g u ided active posterior tra nsl ation or t he C 6-C 7 segments. S i mu l t a neously. mobil ization o r the scar tissue and skin over the c hest and u pper abdomi nal areas and stretching o f the upper p a r t or the rectus abdom inis with transverse mobil ization of the muscle to the right were applied. Stretch ing of lert pectora l i s maj or combi ned with ULNT 1 ( median n erve bias) was performed , addin g sustained end-ra n ge elbow extension with wrist extension . In this position , rotation o r the pelvis to the right ( i . e . relative thoracic rotation t o t h e lert) w a s a I s o added a n d increased the rorearm and upper arm symptoms remarkably (Fig. 2 4 . 4 ) . This technique was a l so d i r ected to latissimus dorsi. These i n terventions l ed to a n i m p rovement o r the shou lder signs a n d symptoms. Application of wrist palmar Ilexion with shoulder i n ter n a l rota tion i n ULNT 2 (radial nerve bias) was fo llowed by an improvement i n the symptomatic response and range of moveme n t of both neuro dyn a m i c tests. S tretching o r the rectus abdom i n i s was performed o n a gym b a ll ( F i g . 2 4 . 5 ) . An i n te res ting response was obtained during th i s abd o m i n a l sort tissue tec h n ique. Dan reported a very i n tense reeling of pins and nee dles i n the whole left upper limb. This was consiste n t ly
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C LI N I CAL R EASO N I N G I N ACTI O N : C A S E STU D I E S FROM E X P E RT M A N UAL TH E RA P I STS
F ig. 24.4
Stretc h i ng of left pectora l i s major c o m bined
with the u p p er l i m b n e u rodyn a m i c test 1 a n d rotatio n of the pelvis to the right.
produced o n ly with t h is tech n i q u e a nd cha n g i n g t h e position o f o t h e r structures ( i nc lud i n g t h e cervica l spi ne) d id n o t i n ll uence t h e respo n se . F u rthermore, while perfo r m i n g the tec h n i q u e with D a n in su p i ne ly i n g ( a n d
with
a l l other components at rest ) . a s i mi
lar symptom response occ u r red , During tech n ique o n t h e g y m
ball.
the abdomi n a l
Fi g. 2 4 . S
Stretc h i ng rectus a b d o m i n i s performed
on a
gym b a l l .
an isometric c o n traction
of transversus abd o m i n i s was added , sim u l ta n eous needJes we re not present at resl. Ra nge o f
wi th stretc h i n g of rectus abd o m i n i s . Following treatments 4 to 5 , an i m provement i n m u scle strength i n t he neurologic a l examination was
of cervical ex te n s i o n was fu l l ,
with
a
movement
d u l l a c b e repro
d uced in the forear m on overpressure . P a l p a t i o n of t h e
Pain in the fo rearm was occasi onally prese n t .
a n terior chest a nd abdom i n a l a reas reprod uced p ins
b u t w i t h minima l and tolerable i n tensi ty. P i n s a nd
and needles i n the posterolatera l a s pect of t he forea m1 .
noticed.
rij
R E AS O N I N G D I S C U S S I O N
What m e c h a n i s m s m ight acco u n t for the
area is from a nterior and latera l c u taneous branc hes of
' i n te resting res p o n se ' you h ig h l ighted w h e re
T6-T8. The i n t ercos ta l nerves communicate with each
u p per l i m b p i n s a n d n e e d l es were co n s i s te n tly
other in the posterior parts of
repro d u ced d u r i ng the abdom i n al soft t i s s u e
(Will i ams
a nd
Wa rwick,
t.he i n tercos t a l spa ces 1 9 8 0 ) . Links a l so exist
tech n i q u e ? H ow d i d yo u r treatm ent a d d ress
between the lower five intercosta l nerves as they com
th ese m e c h an i s m s ?
municate while travers ing the abdomi n a l wa l l . The in tercostobrac h i al ne rve commun icates wit.h the pos terior brac h ial cuta neous bra n c h of the rad ial nerve. rr
• C l i n ician's an swer
the intercostal nerves a re con nected Lo each other,
t h at a
then
Possible neuroanatomica l links may exp l a in this p h e
a
nomenon. The in nervation of the tre ated abdomin a l
exa m ple the abdominal soft tissue techn ique) a p pl ied
reasonable hy pothesis wou ld be
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s t im u lus ( fo r
to
24
o n e or some o f these nerves may b e tra nsmi tted to other parts . In t h i s case, s timu lation of the
1'6-1'8 n erve s may have el icited a response in the in tercosto
F O R EARM PAI N PREVE N T I N G L E I S U R E ACT I V I T I E S shorte n i n g , loweri n g exc i tab i l i ty of a l p h a motor neu rons, rele a s i n g pressure on i n tercostal nerves c a u sed by fibro sis and t i g h te n i ng of the soft tissues, a n d
b rach ia l nerve and s ubseq uently a t the lower pos teri or
i m p roving blood supply to the n e r ves a nd s o ma tic tis
branch o f the radial nerve. This response wou ld h ave
sues . These procedu res were all i n tended to normalize
been possible only if the nervous system was in a n
nervous system activity and i n fl uence motor patterns
a l ready sensitized state. T h i s t heoretical basis might
rela ted to the rib c a ge a n d cerv i c a l spine. Besides the
a l so account for the responses obtai ned d u ring palpa
Significant peri p h e r a l a n d local effe cts o f t h i s s o ft
tion o f the posterior trunk
tissue tec h n iq u e , s u c h m a n u al m a n i p u l a t i o n or s o ft
of
the fifth
are a .
as posterior bra n c hes
and s i x th thoracic nerves su pply t h e s ki n
over t b e sc a p u l a a n d latissi m u s dorsi. The
a bd
om i nal
soft t i ssue tec h n i q u e was
�li med
at
improv i n g fl exi b i li ty of the t i s s u e s . d e c re a s i n g muscle
treatment
t i s s u e s , m u scles < md j O i n ts may al ter i n fo r m a t i o n proces s i n g w i thin
the
cen tral nervo u s sy s t e m b y
mod i fy i n g the q u a l i ty and q u a n t i ty o f its n e u r a l i n p u t
( Vuj novich , 1 9 9 5 ) .
6. D a n d id not com p l a i n of a ny activ i ty
re peated a n d the ou tcomes were si m i l ar t o th ose
restric t i o n s or sympto m s . N e u ro l o g i c a l exa m i n a t i o n
o b t a i ned a t the prev i o u s treatment sessio n . D a n kept
At
rema i n ed uncha n ge d a nd a l l other movements i n
progressing with the home pro g r a m me and was
a l l cons i d e red a reas m a i n ta i n e d t he i r i m proveme n t ,
a s ked to call whenever he cou l d not c o n tr o l his p r o b
i ncluding t h e range o f m otion of the ULNTs and shoul
l e m a n d sy mptoms .
d e r.
On the r i g h t s i d e ,
s e n s i t i v ity to press u re appl ied to
the forea r m was reduced, a l thou g h all other l1 n d i n g s rem a i n e d u n c h a n ged . The home prog ramme was revisited . combin ing cer vica l spine extension a n d tru nJ< extens i o n in prone ly i n g Pectoralis major s tretch i n g in the ULNT .
1
pos
i tion wi th wrist extension a n d ri g h t pelvic rotation was added . The plan was to review the patient
2 weeks l a ter.
• Treat m e n t 9 More tha n a mon th a fter the l a s t treatme n t . D a n asked fo r a s s i s t an c e . He h ad s p o n ta n e o u s p a r a esthe siae i n the l e ft u p per limb not related to a ny p a r t i c u l a r movement or activi ty. Cervical s p i n e exten s i o n w a s norm a l . Ex a m i nation o f t h e s o ft tiss ues o f t he a r m
• Treatment 7
a n d fo rearm revea led tenderness a nd reproduction of
Dan was re-ex a m i n ed a fter 1 9 day s . During this period,
d o r s a l fo rearm muscles. Pal p a t i o n of the r a d i a l nerve
lateral forearm pain reappeared slightly. Cervical spine
i n the poste ri o r p a r t of the arm a lso reprod uced p i ns
p i n s a n d need les on pal p a t i o n of the triceps and
extension was slightly restricted with overpressure and
a n d needles i n the pos terior a s pect of t h e fo re a r m
reproduced a d u ll pain in the forearm. A l l previou sly
a n d hand. Treatment focussed o n d esensitizing the
detected areas of al lodynia were free of sy m p toms d u r
invo lved t i s s u e s , i n c lud i n g friction m a ssage o f the
i n g pa lpation, except for an area in the posterolateral
radi a l n e r ve. Following tre a t m e n t Dan repo r ted n o
part of the arm . Assisted active cervical posterior tran s
compl a i n ts .
lati on was repea ted concur ren t ly vvit h t he soft tissue tec h n ique to the deep cervical muscles . Ski n mobiliza tion tech niques were performed to the sensitive area of the arm. Follow i n g these techn iques. range of move ment of the cervical spine was normal with n o symp toms produced on overpressure.
recu r red
D a n kept u p w i t h the home prog ramme. In genera l , D a n returned t o max i mal fu nction and symptoms were min imal. However, i t was expected that there could be occasional b o u ts of symptoms. Dan was d i s
• Treatment 8 The forearm ache
• O utcome
c h arged w ith the option o f retur n i n g fo r 'on-ca l l ' a fter
3 d ay s , b u t was very
treatm e n t whenever req u ire d .
low in i n tens i ty. S i mil ar tre a t m e n t tec h n iq ue s were
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C L I N I C AL R EAS O N I N G I N ACT I O N : C A S E STU D I ES FROM E X P E RT M A N UAL T H E RA P I STS
R E AS O N I N G D I S C U S S I O N AN D C L I N I C A L R E A S O N I N G C O M M E N TA RY
D
T h e re a p pears to h ave been a n u m b e r of
to t h e r i g h t t h a n to
d i ffere n t s p e c i fi c phys i c a l i m pa i r m e n ts that
o f the tissues o n t h e left s ide of t h e tru n k a n d u p per
the left. Tig hten i n g and sti ffen i n g
you j u dged were con tri b u ti n g to th is pati e n t's
l i mb may explain the res tric ti on of thoraCic rotation
presentat i o n a n d hence a d d ressed i n yo u r
to the right. These tiss ues i n clude p e c to r a lis maj or and
manage m e n t. C o u l d you d i s c u s s yo u r thoughts
m i n o r. latissimus dorsi. the left cer vical muscles a nd
on the re l eva n ce a n d i n te r p l ay of these p hysical
soft ti s sues . t h e left abd o m i n a l muscles, a n d the left
i m pa i rm ents i n t h i s case?
erector s p i n a e . Co ns eq u e n t ly. rel ative rotation of the tru nk to the l e ft may h ave occurred . exp l a in i n g the re lative l i m i t a ti o n o f left cerv ica l rotatio n , res triction
• C l i n i c i a n 's an swe r
o f t h or a cic rotation to the r igh t and the re s tricted
Ma n a g i n g specitk ( e . g . a res t r icte d cerv ical segmen t) .
mobil ity
of the l e ll s h o u ld er.
g en eral (e. g . inabil i ty to s leep in p rone ly ing) and men tal ( i . e . pa t ien t 's feelin gs or cogn itive i n terpretations)
tion of the scapu la and t h e tight pectora l s . the el bow
dysfu nctions in m a n u a l t her a py requ ires c o n s id er i n g
m i g h t h ave been a ffected th ro u g h i nvo l vement of
ConSideri n g the pOS ition of protrac tion and eleva
the hu man body as a n in teg ra te d fu nctio n in g system
the biceps m u scl e . In a d d i t i o n , sc a p u l a r protraction
where a l l o f its par ts are l i nked a nd function as
encou rages lower c er v ic a l flex io n . perhaps a dd i n g to
a
whole :
l read y restricted segmenta l m o b i l i t y in the d irec
referred to b y Butler ( 2 000) as a ' b i g picture ' approach .
the
This was the a p p roach a d op ted in t h e mana gement o f
tion of exte n s i o n . This c o u l d expla i n the l i m ited range
th i s p a t ient
( a nd
shou ld be a fu ndamental principle in
m anu a l therapy practice) . T h e employ ment of lateral
a
or movement at the e lbow and may h ave a l so led
to
a p attern of inter n a l rotation of the whole u p per
thinking str a tegi es (i .e. looking for m u lti p le alterna
l i m b. A n i n ternally r ot a te d u pper l i m b can lead to
tives, even those that seem to be u n l ikely or even ridicu
general res triction of exter na l ro tation and may c ause
a
lous) had gu ided the process of hy pothes i s generation
impingement-like sho u l d er symptoms. This could a lso
from the start. From the begin n in g of the paLient
cause a seco nda ry i m p a i r m e n t of the nerves of the
encou n ter, t he aim 'Nas to work out wh at could have
upper l i m b and c o n t r i bute to a l tered ne uro d y n a mics.
led to Dan's imp a irm e n t and fu nc t i ona l prob lems . As
Rectus abd o m i n i s i n serts o n to the s te r nu m . A ny
mentioned above . i t wou l d have been na ive and s implis
in terference wi th the a n a t o my of the stern u m (such as
tic to think that the nerve root (or dorsal root ga n g lio n )
car d iac surgery) may i n fluence muscle a l i g n ment a n d
o n ly struc tures
mec h a n ic s . Rectus abd o m i n i s i s consi dered a ' whi te '
r es p o nsi b l e for Dan ' s symptoms a n d dy sfu n cti o n . If
muscle w i th the ten de n cy to s h o r t e n . S h o r tening of
cmd
intervertebral d i sc
were
t he
th i s had been the case, treatmen t wo u ld have been
th i s musc l e may l e ad to i m pa i red mo bility of the rib
d irected solely to these structures. However. the multi
cage a n d consequen tly to rest r ic ti o n of cervical spine
ple sou rces and components res p o n s i ble for Dan ' s
movemen t s , not a bly exte n s i o n a nd rotation consid er
sy m p toms and d ysfunc tio n would have been misse d ,
i n g possi b le asym metry obta i ned or reinforced fol
a n d trea tmen t w o u l d h ave b e e n i ncomp l et e or even
lowi ng su turing of the ster n u m d u ring t he surg ical
ineffective. All the impairments t h a t were add ressed
proced u re. This may h ave c o n tr i b u ted to the degenera
d ur in g treatment were aU pieces of
a
larger puzzle.
The v a r i o u s i m p a irme n ts addressed d u ri n g treat
tive process of t he d isc thro u g h i m p a i red nu tr i tio n and metabo l ism.
ment were o bviousl y rel ated to each other and ind i v idu a l ly c o n tri b u ted t o the n e c k proble m . The cervical
F u r thermore,
a
l oss o f lumbar spine ex tension a lon g
w i th s h o r tened hamstrings could c a u se a posterior
s p i n e is the mo s t mob i l e a rea of t h e s p i n e ; h oweve r.
pelvic tilt and a concu rren t t horacic ky phosi s . leading
local pr o b lems or p hy sic a l i m p a i rmen ts dista n t to the
to lower c er v i c a l flexion a n d m i d - to - u p pe r cervical
cervical s p i n e m ay have a s i g n i fic an t impact on cer
extens i on .
v i c a l spine movemen t . The r i b c a ge and tho rax pl ayed
A l l these rel ated impai rments a r e orche s tr a ted
a maj or role in this c a s e . As o bserved d u r i n g t he phy s
thro ug h the cen tra l nervous syste m , which m ay
ical exa m i n a ti o n . t horac i c rotation was more limi ted
p rovoke
Copyrighted Material
abnormal
movement
pa tterns.
sensory
24 FOREARM PA I N PREVENTI N G L E I S U R E ACT I V I TI ES abnormalities , abnormal sympathetic fu nction and behavioural i n fl uences.
You mention that you expected there could be occasional bouts of symptoms in the future fo r thi s patient. Cou ld you comment on the
H ow would you manage your stated pla n for fur
key s u pporting evidence fo r th i s prognostic
ther 'on-call' treatment fo r this patient
hypothesis?
without increasing the r i s k of dependency on yo urself and pa ssive treatment?
• C l i n ic i an s answe r '
Every phySical i n terven tion (or inj u ry) leads to a
• C l i n i cian's answer It was hy poth e s ized during the c l i n i c a l assess ment of t h i s pa t ie n t that the risk of d e pe n de n c y o n the system was low fo r D a n . Nevertheless, my plan w a s for Dan to be i ndepe n d e n t or others in managing fu ture symp toms. On the one ha n d he was used to responsib i l i ty i n that he had to keep his busi ness going a n d cou l d not rely on anyone else to replace h im or to do his j ob. The fac t th a t he was the owner o f the fa ctory was i mpor tant. On th e other han d , he did not pay much atten tion to his p hy s i ca l cond ition because o f th at very fa ct. This could have been a nega tive fa ctor in cooperation and i t was my impression that this attitude was i n i t i al l y a n o bstac le for h i m t h a t h a d t o be removed . During the cou rse of m a n a ge me n t . these issues were d i scussed at len gth : in time I became con fident that he was cooperating with the home p rogramme. on the
basis of mai ntenance of the i mprovement a nd by c hecking e a c h tre a tment session how be was perform ing the exercises and a p p lyi n g my i n str ucti o n s . I n a d d i ti o n , D a n ' s active par ticipation during tre a t men t ( for example active neck retrac tion while per for m i n g posterior tra nslation. as we l l as contractions o f transversuse abdominis and s tr e tch i ng rectu s) conveyed an importa n t message. The fact tha t he had to be ac t iv e d u r i ng treatment sh owed hi m th a t active movement was possible (even i f reproduci ng the symptoms) a n d t h a t i t h ad a h e a l ing potential. Dan u n d erstood that i t was worthwh il e perrormi ng move ments because d oi n g so may improve h i s condition . T h i s is an extremely important message. The a i m i n almost every clinica l intervention should be t o achieve active participa tion of the p a t ient d ur i n g management and decision making by adopting a patient-centred appoach in cli n i c a l reasoning (Higgs and Jones, 2 0(0). First. forces exerted by the patie nt can sometimes be greater tha n forces appl ied ma n ua l l y (such a s when mobi lizing a n ankle i n w e i g h t bea ring while the patient performs dorsi flex ion) and. second ly, it has a psychological impact a n d m ay reduce fea r-avoidance behav i o u r s .
' l e ar n i n g process ' i n the nervous system. As the prob lem was i n itia lly hypothesized to be a n ac ute m a n i festation of a c h ronic disorder. i t was ex p e cted that until the nervous system was fu l l y reset there m i g h t s t i l l be occa s i o n a l b o u t s . It is no t clear h o w l o n g i t c a n take [or t h e n er vo u s system to retu r n to i t s i n i ti al s tate and whether th is occurs at a l l . T he behav i o u r o f the disorder d u r i n g the phy sica l exam i n a ti o n and treat men t demonstrated an increased sensitiv i ty of the nervo u s system . D u ri n g treatmen t. Dan had sponta neous relapses o[ symptoms with n o obv ious cause and wh ich were n o n-speci fic in n a ture and d is tr i b u t io n . Central ly med i a ted p a i n a n d symptoms p r o v id e the best expla n a t i o n for the fact that ma ny areas in the b o d y reprod uced the symptoms of forearm pain o r p i n s a nd need les even t h o u g h they were n o t a n atom ically related to the a r m . Cen tra l ly med i a ted pain (a n d other symptoms) may leave a ' memory of p a i n ' in the central n er v ou s sy s te m (Basbaum. 1 9 9 6 ) , a p h e nom enon ca l led n e u ronal p lastici ty. Neuronal p l asticit y refers to fu ncti o n a l and p l a s t ic cha nges i n the ner vous system as a resu lt or pain o r other pe r i p he r a l i n put (Dubner. 1 9 9 7) . It has been shown that centra l sensitization a lso occurs as a result of ' wi n d-u p ' (Li e t aI . , 1 9 9 9 ) . Wi nd-up refers to the repetit ive stimula tion o f C fi bres. le a d i ng to a progressive i ncrease in the magnitude of C fibre-evoked res ponses of dorsal horn neurons. These theoretical explanation s m i g h t ex p l a i n the p h e n o m e n a observed i n t h i s c a s e . A s a res u l t . it was expected tha t ' r ese t t i n g ' the nervous system migh t take longer bec a u se of the g r a d u a l ' relearning' of the syste m .
• C l i n i cal
reaso n i ng c o m m e n tary
M a n u a l therapists are o fte n accused of overservic
ing. In the absence of l e ve l 1 evidence (random ized trials) for many of our interventions, especially as t h ey are often a p p l i e d in co m b in ation , our best safeguard against unsubstantiated exces sive treatment is our own rel1ective r e a so n in g . This controlled
Copyrighted Material
C LI N I C A L REAS O N I N G I N ACTI O N : C A S E STU D I ES FROM E X P E RT M A N UAL T H E RA P I STS
requ ires
• Acknowledgments
hol is tic and critical biopsychosoc i a l per
a
spective th at draws
on
wh a t is u n d er s t oo d in p a i n
I wish to exp ress my g ratitude to my w i fe Nurit for
science (while recognizi ng much i s still n ot under
bei n g my other h a l l'.
stood abou t pain and i ts complex i n terplay with
I wou ld a lso l i ke to th a n k Yossi S adovnik la r taki n g
the d i fferent b ody systems ) . and which is gui ded by
t h e photograp hs a n d Illa n Sh aoul, stud ent o f p hysio
an open-minded yet cautiou s systematic approach
therapy, for ser ving a s
of i n terven tion and reassessment. The reaso n i n g
24. S.
evident in t h i s
c a se
patient
and
an
model in F i g u res 2 4 . 4 and
ill ustrates j ust such a broad
and questio ning ap proa c h to
on e that. involves
a
manual therapy. and
a c t ive partner ship be tween
therapist in
the
man agemen t
of
c hronic c l i n i c a l pro b lems .
• References A . !, ( 1 9 9 6 ) . M e mories o f pa i n . 3 . 2 2- 3 1 . Bogd u k . N . ( 1 9 9 4 ) . Biomec h a n ics of the cerv ical spine. [ n Phy s i c a l Basba u m .
Science a n d Med icine.
Therapy of
the C e r v i c a l a n d
( M a her. C . ed . ) ] Austra l i a n j o u r n a l o f Physiotherapy Monogra p h .
3 . 1 3 -1 7 .
G r ieve. G . P. ( 1 9 9 4) . T h e a u to n o m i c
L i v i n g stone.
p p . 2 5 9 -2 6 9 . Ed i n b u r g h :
Bogd u k .
N . ( 1 9 9 7 ) . C l i n i c a l A n atomy of
the Lu m b a r Spi n e a n d
Sacrum.
Ed i n b u rgh : Church i l l L i v i n gstone. B u t l er. D. ( 1 9 9 8 ) . Adverse mecha n i c a l ten s i o n i n t h e nervous syste m : a model for a ssess m e n t and trea tment
ed.)]
J.D. a nd
A u s t ralia n j o u r n a l
N . cd s . ) C h u rchi l l
Livingsto n e . Hasue.
M. ( 1 9 9 3 ) . Pa i n a n d t h e ner ve
1 8 . 2 0 5 3-20 5 8 . A.R. ( 1 9 9 7). Neu ropa thic p a i n in t h e perioperative
Spine.
Hayes . C . and Molloy.
Anesthesiology
3 5 . 6 7-8 1 . Higgs. J . a n d Jones. M . ( 2 000) . Cl i n ical C l i n ics.
V ( 1 9 8 8 ) . Muscle weakness a n d
i n h i bition (pseudoparesis ) i n back p a i n
Noigroup Press.
sy n d romes. I n Moder n M a n u a l
G . r. ed . ) p p . 2 5-40 . Sea ttle.
D u b nel',
( G rieve. G . P. e d . ) pp. 1 9 7-2 0 1 .
It ( 1 9 9 7 ) . N e u ra l basiS of
a
strategic view. In Comp lex Regio n a l
persiste n t p a i n : sensory spec i a l izati o n .
P a i n Syndrome ( N o r m a n Harden . R . .
sen sory mod u lation a n d neuro n a l
Baro n .
p l a st i c ity. I n P roceedin gs o f t h e Eig h t h
p p . 3-1 5 . Seattle. WA : I A S P Press.
T. S . , Z . eds . ) pp.
World C o n g ress on Pain (Jense n . Turner. J. A . a n d Wiesenfe l d .
2 4 3 -2 5 7 . Seattle. WA: lASP Press. M. ( 1 9 8 5 ) . Con nective Tissue
Ebner.
Manipul ation. M a l abar: Robert E. Krieger. Elvey.
R. ( 1 9 9 8 ) . Tre a tment of arm p a i n
associ a ted w i t h abnorm a l brac h i a l
R. a n d Jan i g , w. e cj s . )
Li . J .. S i mone, D.A. a n d L ar s o n .
A.A.
c h aracterist.ics of centra l
sensi tiZa t io n . Pa i n . 7 9 . 7 5-8 2 .
fro m
skeletal muscle i n re lation t o c l i n i c a l muscle p a i n .
( 1 9 9 5 ) . N e u ra l plasticity. tissue
m a n i p u l ation : a review of lhe
0[' Manual a n d 3. 1 5 2- 1 5 fl . Wa l l . P ( 1 9 9 9 ) . Pa i n-The Science o f S u fferi ng. Lo n d o n : Wei n den feld and l i teral ure. Journa l
WiU i a m s . P L . a n d Warw ick.
Pa i n . 5 4 . 2 4 1 -2 8 9 .
Ness . T.J. a n d Gebh a r t . G . E ( 1 9 9 0 ) .
C h u rc h i l l Li V i n gstone.
G .) . . Doherty. M. a l . ( 1 9 9 8 ) . Towards a mechanism-based classification o f p a i n ? Pa i n . 7 7 . 2 2 7-2 2 9 . Zer m a n n . D . H . . [shigook a , M . . Doggwei lcr. R . a n d S h midt. R . A . et.
' ( 1 9 9 8 ) . Pos topera tive chronic pa i n and
b l a d der dysfu nctio n : w i n dup a n d neuron a l p l a s t i c i ty : do w e n eed a m ore n e u ro u rological approach i n pelvic
plexus te n s i o n (co m m e n ta ry) . [In
Viscera l pa i n : a rev iew of exper i m e n ta l
s u rgery? jour n a l
'Adverse neunJ l tension ' reco nsidered
s t u d i e s . Pa in . 4 1 . 1 6 7-2 3 4 .
1 6 0 . 1 0 2- 1 0 5 .
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R. ( 1980).
Gray's A n a tomy, 3 6 th ed n . Edin burgh: Woo l f. C.J .. B e n n ett.
( 1 9 9 9 ) . W i ndup leads to
Mense. S . ( 1 9 9 3 ) . Nocicep tion
Vuj novic h . A . L.
N i colso n .
Ed i n b u r g h : C h u rc hi l l Liv i n gs to n e .
w. ( 2 00 1 ) . C R P S - I and CRPS-I ! :
S n ijde rs. C. a n d Stoe k a r t .
M a n ip u la tive T h e filpy.
Therapy of t h e Ver tebra l C o l u m n
Ja nig.
WA : IASP Press.
A . . Moon ey. V. . Dorm a n . T. R. ( 1 9 9 7 ) . Movemen t Stabi l i ty a nd Low Back Pa i n : The Essl' n t i a l Role or the
Vlee m i n g .
mus c l e spasm a n d
Nervous Syste m . Ade l a ide. Austra l i a:
( Ge b h a r t ,
of the cerv i c a l
Pe l v i s . Ed i n b urgh : C h u rch ill
Reas o n i n g i n the Hea lth Profess io n s .
F. (J 9 9 5 ) . Mecha n isms of
a n a to m i c re l a t' i o n a mong the n erve
L i v i n gsto o e .
Oxford : B u tterwo r t h -He i nem a n n .
v iscera l pain. In Viscera l Pa i n
N . . F u j i m oto. Y. . A n . H . S .. Y. a n d Ya su d a . M . ( 2 000 ) . The
s p i n e . Spine. 2 5 . 2 8 6 -2 9 1 .
3 3 -3 5 .
Cervero.
Ikuta.
in tervertebra l d i scs
root. An i n terd i scipl i n a ry ap pr o ach .
Janda ,
in
roots. i n tervertebral [(m, m i n a . a nd
o f Physioth erapy M o n ograph . 3 . B u tler. D . S . ( 2 00 0 ) . The Sensitive
P. a n d
L i v i n g sto n e . Ta nak a .
Palastanga.
period . Internati o n a l
( c o m m e n t a ry ) . [In 'Adverse Neura I Tens i o n ' Reco n s idered
( M a h er. C.
(Boyli n g .
H o d ges.
Low B a c k Pa i n . Ed i n b u r g h : C h u rc h i l l
s y n d romes. T n Griev e ' s M o d e r n M a n u a l Thera py : The Ver teb ral Col u m n
C. . J u l l . C . .
Hides. j . ( 1 9 9 9 1 . The rapeu t i c Exercise for S p i n a l Segmental Sta b i l i za tion
nervo u s system i n vertebra l p a i n
R. e d . ) p p . 2 7-4 5 . Ed i n b u r g h : Churc hill Thoracic S p i n e ( G ra n t .
R ic h a rdso n .
of U r o l o g y.
T h e o ry an d d eve l o p m e nt
E d ucati on a l t h e o ry and p r i n c i p l es rel ated to l earn i n g c l i n ical reas o n i n g
379
Joy Higgs I m p rov i n g c l i n ical reaso n i n g in m a n u a l the rapy
403
Darren A. Rivett and Mark A. Jones
Copyrighted Material
377
C H A PT E R
E d u cati o n al t h e o ry an d
25
p ri n c i p l es re l ated to l earn i n g c l i n i cal reas o n i n g
Joy Higgs
I ntroduction
-
-
.
This book is primar i ly addressed to prac tit i o n e rs such as p hysiothera pists, c h i r o p r acto rs a n d o th er hea l t h p r o fess ion a ls working in t h e field of m a n u a l therapy. Some read ers w i l l be te ac her s , some mentors o f j u n i or co lle a gues a n d some wi l l be l ear ne rs . The task of this c h ap t er is to ex plore ed ucat i o nal d iscou rse , t h e o ry a nd principles re l eva n t to te a ch i n g a n d l ea r n i n g c l i n i c a l reason i n g . T h e p ra ct ica l a p p l i ca tion s of t h i s t he ory to l ear n ing clinical re asoni ng poses an i n teres t i n g c h al lenge a n d a n u mb er o f quest.i o n s , wh i c h reflect the star ti n g po i n t of a ny ed u c ati on a l endeavo ur, W h a t is the topic or s u bj ect
of the te aching exercise? Wh at
assumptions c a n be made a b o u t t h e reader s ? What go als do they h ave, compared
with
the goa l s of the
of the t o p ic that reasonably be covered to ad d r ess th ese go a ls? W h a t l a n g u age a n d s tyle of ' teach i n g ' (or wr i ti n g ) are a p p ropri a t e for th e audience, go als a n d content? One o r t he purposes of educational theory and its teachers? What is the scope and depth
can
ap pl ication is to
typica l
of
process-incl usive
lea r n i n g
progra mmes
(Ever i n gham a n d B a ndaran ayal<e , 1 9 9 9 ) , which d e l ib
ar t i cu l a te
and mal,e transparent the
answers to t hese very q uestions , In
e rately target, exemplUy and
de pic t the p rocesses of
t h inking a nd reaso n i ng as c o re values, go a l s a nd learn ing o u tcomes .
Th is c ha pte r is written n o t fo r n ov ice tea c h ers a n d rather for ex pe r i e n ced practitioners w h o h ave practi c a l experience o f tea c h i n g a n d l e a r n i n g , w h o a re a c t ive ly e n g a ged i n their o w n le ar n i n g a nd i n fa C i l i tat i n g t h e l e ar n ing of o t h e r s , The goa l of this c h a p te r i s to ex tend o r consolid a te readers ' know led ge of ed ucati o n a l t h e or y and d i scourse and to pro mote re flec t i o n on the use of ed uc a ti o n a l k no w l ed g e as a t o ol to fa c i l itate sel f-dire cted l e a r n i n g or to h e l p others t o l e a r n . Th e ch a pter is a lso a bridge between C ha p te r 1 . which d e a l t w i th c l i n i c a l r e a s o n i n g i ts e l f i n m a n ual t h e r apy, a n d Chapter 2 6 , w h i c h co n s i d e r s w ays o f fa ci Utating c l inical reaso n i n g develop men t . l e a r n e rs b u t
What is expected of health sci e n c e grad uates?
this way, education
i s simi lar to cl in i cal practice, in that our stal<e ho l d ers
The go al of
expect professi on al s ( educators and clin ici a n s ) to be
autonomous, competen t profeSSion als who can de m on
most curricula today is to produce
accou ntable for their prac tice and to be able to ar ticu
strate d iscipline-specific tec hnical
l a te the r ation a l es , decisions and strategies which form
who act professionally.
the basis of this practice . When an a d ult lear ning
em p hasis recently o n add i n g t o curricular expectations
competencies and T here has been an i ncreaSi n g
approach i s adopte d , the common ele men ts o f aware
the acquisition of ge n eric compete ncies , i n c l u d i n g
ness of th inki n g an d cogni tive s tra tegies , res po n si b ili ty
i n terpe r so n al ski l l s , problem-sol v i n g skill s ,
and
competence and competence i n i n for m a tio n technol
articu l ation of thinking are reflected in bo th the
cultural
learning process a nd the l earn i n g conte n t , cre a ting a
ogy (Hunt a n d Higgs , 1 9 9 9 ) . Health p rofe ss ion a ls are
powerru l sy nergy between
the two, This matching of
ex pec ted to demonstrate soc i al res p on s i b i l i ty (Prosser,
the process an d con ten t of learning programmes is
1 9 9 5 ) . acc o u n tabil i ty a n d the c a p acity to recog nize
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3 79
UN
T H E O RY A N D D EV E LO P M E N T
u n q u estioning s u pport of na rrow
their l im itations ( S u ltz e t a l . . 1 9 8 4 ) . to practise w i t h
factors , a l o ng with
i n tegri ty a n d persomd tolera nce. a n d t o communicate
views of evidence-ba sed practice, c h a llenge t h e auton
effectively a cross l a n g u a ge , c u l t u r a l and s i t u a t io n a l
o my o r pro [essi onaJ decision m a k i n g a n d i n c rease the
b a r riers ( Jose b u r y et a I . , ] 9 9 0 ) .
need for profess ionals to have j usti llable conlldence i n
The capacity t o a c t a s a u to n o m o u s profess i o n a l s i s a cen tral concept in professional practice. Professi o n a l
the sound ness a n d d e fensi b i l i ty o f t h e i r reaso n i n g : sou nd reaso n i n g i s more i m portant t h a n ever.
au to n o my imp lies i n d ependence in decis i o n m a k i n g a n d a c ti o n , accepta n c e of respo n s i b i l i t y for acti o n s take n ,
t h e d e m o n s tration
and
of
acco u n tab i l i t y
towa rds those w h o rec e i ve the s e r v i ces 0 (' t h e profes sio n a l . The capacity to m a ke defe n s i ble c l i n i c a l d eci
So, how c a n we ac h ieve these teac h i ng a n d l e a r n i n g
s i o n s relies on
sound k n o w l edge base. skil ls i n c l i n i c a l
g o a l s ? Ed u c a t i o n a l theory provi des t h e fra mework
and t h e capacity to
( t he go a l s rat i o n a l e , con tex t . p h i losop h i c a l b a s is and
a
reaso n i n g a n d meta cogn itio n ,
,
faci litati on of l e a r n i ng . In a ny
i nteract effec tively w i t h other partic ipants ( espec i a l ly
g u i delines) fo r the
the clie n t ) in the decision-maki n g p rocess. Compete n t
p a r ti c u l a r s i t u a ti o n , t he t a s k fac i n g the
cl i nici a ns need n o t o n ly t o b e able t o make a u tonomo us
the s e l f-d irected l e a r ne r who is p l a n n i ng l e a rn i ng
decisions but a lso to be able to take ' w i s e ' acti o n , mean
e d u c a to r
or
a ctivit i es is to ch oose ed u c a t i o n a l t h eory a n d re lated ( i n t h is c ase, l e a r n
ing taki ng the best ju d g ed action i n a speciJlc c o n text
strate g i e s appropri ate to the to pic
( Cer vero ,
i ng c l i nica l reason i n g ) a n d t h e s i t u a t i o n . T h i s c h apter
-
1 9 8 8 ; Har ri s , 1 9 9 3 ) . A l ongside the pri v i lege a u t o n omou sly, professi o n
p u rs u e s a n u mber o f key q uestions fa c i n g peopl e
a l s n e e d t o be a b l e to make s o u n d , i n d ependent.
d e s i g ni n g l e ar n i ng prog rammes. whether to facil i t a te
and the obl iga tion to
wo r k
accountable decisions a nd to impleme n t them in a
t h e i r own lea r n i n g or tha t of o t he r s , a n d provides
s p i rit of criti c a l appraisa l. Today, more than ever. pro
r a n ge of e d u c a t i o n a l th eories and issues a riSi ng from
fess i o n a ls are fa c i n g a c l i mate of c h a l l e n ge and con
rese a rc h , theorizin g a n d experience that a d d resses
a
( e . g. a d u l t
tes t a tion, where pro lessionaJ j u d gme n t i s su bject to
these q u estio n s . Some o f t hes e theories
increa sed publ ic scrutiny, where there i s lack 0 (' consen
lear n i n g ) could be d i scussed u n der a n u mber of head
sus o n what expertise comprises and where authori ty
i ngs a n d t here are many a re a s of overlap and compati
b ased cl a i m s are u n d ermined (Frost.
Learning styles
2 0 ( 1 ) . These
bil ity among these theories
and pri n c iples . r i g ure 2 S . 1
Trends in health care Professional practice
Humanistic and
Professionalism
emancipatory education
Generic and professional
Social
competencies
responsibility
Capacity to
Change agents,
perform as
problem solvers
autonomous professionals
Learning how to
(clinical
learn
reasoning)
Learning for capability
Situated learning Sociakultural-hlstorical learning
F i g. 2 5 . 1
I d e n tifying relevant lea r n i ng t h e o r i e s a n d d i sc o u r s e .
Copyrighted Material
2 5 E D U C ATIONAL T H E O RY A N D P R I N C I P LES R E LAT E D TO LEARN I N G C L I N I CA L R EASO N I N G i l l ustrates this pr oc e ss and framework. T h e next c h a p
reaso ners. p ract i ti o n e r s clearly use k n owledge as an
ter deals with s tra t e gi e s uti l iz i n g these theories to pro
e s s e n t ial reaso n i n g too ! . They n eed to be a b l e to trust
( t h ro u g h tes t i n g , l e arn i n g a n d cr i t ic a l se l f- a p pra isa l )
mote the lear n i n g or clinic a l reasoning.
t h i s lm o w l e d g e . a n d they need to be <J b l e to articu l ate
• What i s known and u n d e rstood about t h e p h e n o m e n o n being taught?
To u n d e r s ta n d t h e p h e n o me n o n being ta u g h t , we n ee d Lo rdl ec t on t h e ava i l able k n o w l e d g e in t h e field i n q u e s ti o n ( i .e. c l i n i c a l reasoning) . What types of knowledge h ave been g ener ate d abo u t t h i s topic? How d o we come to know ab o u t th i s p h e n o m e n o n ? A n u n d e r s t a nd i n g or fo u r key fa c to r s a d dr es s e s t h e s e q u e s t i o ns : • c l i n i ca l re a so n i n g p rocess
of
ge nerati ng
knowledge / practice
ep i s te m o l o g y
rev i e w of t h e pr o fe s s i on ' s k n o w l ed g e b a se (Tilchen
and Higgs. 2 00 1 ) .
Forms o f p racti ce know l e d ge
S inc e C h apter 1 ex a m in e d
Hea l th p r o fess i o n a l s seek to
make sense 0 1
c l i e n ts ' or
patie n t s ' p r o b l e m s by d r a w i n g on their k n o w l e d g e. T he k n o w l e d g e that c l i n i c i a n s bri n g to the c l i n i c a l
• practice k n o w l e dge .
en c o u n t e r is
clinical reasoning and
metacognition in de p t h . those to p ics are n o t re pe a ted here. In see k i n g pr a c ti ce k n ow l edge . the te acher rec ognizes the v a l ue o f the e d u c atio n a l p r i n c i p l e that cal ls for t ea ch er s to h ave (or to h ave a cc e ss to) content k n o w l ed ge , a s wel l a s k n o w l e d ge and s k i l l s in the p r o c e s se s o r te ach i n g . S i m i l a rly, for learners. there is a
endi n g process of critic a l a p p r ais a l . ex te n s i o n and
What ty pes of k n o w led ge do pr a c t i ti o n e r s need ?
• m e t ac o g n i t i on • the
the s o u n d reason ing behind t heir c l i ni c a l decisions . To demonstrate accountabil ity ro r their practice, c l i n icia n s need to u n d erstand the n a t u re of t h e i r d y n a m i c k n owled g e b a s e , so t h a t they c a n expl ore i ls c o m plex ity, a p p l y i t a p p r o p r iate ly and partic i p a te in the never
ne ed to know what i t i s th ey are s e e ki n g to know.
a
k ey aspect o f
t h e thera peutic interve n
tion (Jensen et a l . . 1 9 9 2 ) . T h is k n o w l e d g e can be c a t
e g o r i z e d ( H i gg s a n d Ti tche n , 1 9 9 5 a . b ) a s : • pr o p o s i t i o n a l . t h e o r e t i c a l or s c i e n t i fi c k n o w l ed g e • p rofess i o n a l c ra ft k n o wl e d g e . o r k n o w i n g how t o
do s o m e t h i n g • pe rs o n a l knowledge abou t o n e s e l f as a person a nd in r e l a t i o n s h i p w i th o t h e rs .
Propositional knowledge is d e rived t h r o u g h r e se a rc h a n d / o r s c h o l a r ship . It is fo rmal a n d e x p l i c i t know
P racti ce e p i ste m o l ogy
l e d ge t ha t is ex pressed i n pr o p o s i ti o n a l statements,
P ra ctic e ep i st emo l ogy rders to the n a t u re o f know
w h i c h e nu n ci a t e , for ex a m p l e , r el a t i o n s h i p s between
l e d ge a n d kn o w l e d ge generation that underlies pr a c
concepts o r c a us e s a n d e ffe c l s a n d w h i c h i d e n ti fy the
tice ( see Hi gg s et a l . .
generalizability or tr a n s fe ra b il i t y o f resea rch k n o w
2 00 2 ) . The q u e s t i o ns o f pra c t ice
ep i s t e m o l o gy are o r fu n da m e n t a l impor tance for the
l ed g e to pop u l a tions a n d setti n g s . T heoret i c a l know
q u a l i ty a n d u n de r s tan d i n g of pra c t ice . T h e c u r rent
ledge may be developed fro m a r gu m en t s of p r i n c i p le .
c l imate o f a cc o u n t ab i l i ty and p u b l ic scru tiny i n the
from d i a l o g u e and l o g i c . and thr o u g h use of existing
h e a lt h a n d s o c i a l c are p ro fe s s io n s requ i res the adop
e m pi ric a l a nd theoretic a l k n ow le d g e .
tion o f a h i g h level of r es p o n s i b i l ity by health pr o fes
sion a l s
in
t e r m s of
u ndersta nding, scrutin izing, ge ne r a t i ng , u p d a t i n g and cre d i b ly u si ng t he ir p r o fe s s i o n a l kn ow l ed ge . To a c h ieve this, health pro fes s io n a l s need to a ck n o wle d ge the w i de variety of sources from wh i c h their k n o w led g e is g e n e rat e d , to u nd er sta n d
Professional craft kn o w led ge and pe rso na l know ledge are c o llective ly called non-propositional kn o w
ledge. They are derived from the processin g (e.g. thro u g h reflection) of professional and pe r so n a l experiences. respective ly, and m ay be taci t and embedded in prac tic e
n i ze pra c ti ce e p i s t e m o l og y as a necessary d i m en sio n of p r o fess i o n a l re s po n s i b i l i ty. Th e i m p li c atio n s fo r
or in the personal i de n ti ty and lives of the knowers . Cervero ( 1 9 9 2 . p. 9 8 ) descri bed p r ofess i o n a l craft kn ow l e d g e as a 'reperto ire of examp les , images, pract ical pr in cipl es . scenarios or ru les of t hum b that have been de vel ope d through prior exp eri e nce ' . Professional
c l i n ica l reaso n i n g of these arguments for lear n i n g
craft lmowl edge comprises general Imowledge gained
programmes a r e rela tively tran sparent. A s clinical
from practice experience (e.g. lm o w l e d ge about how
the know led ge that u nderpi n s t he i r practice, to j u stify
their p r a c t ic e t hrou gh this knowledge, and t o re c o g
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no
T H E O RY A N D D E V E L O P M E N T
a popu l a t i o n of patients respond t o disease or d i sab ility)
practi tioners to re l a t e we l l to t h e i r c l i e n ts as i nd ividu
par t i c u l ar patient. i n
a ls w i th unique need s . fe ars. h o pes and ex pectati o n s .
a p ar ti c u l ar situation a n d contex t at a particu l ar time.
C a r per ( 1 9 7 8 , p. 2 0 ) argued th a t perso nal knowledge
and speciflc know l edge about
a
Professi onal craft knowledge can be expressed in propos
' p r o mo te s whole ness a n d i n tegri t y in the perso n a l
itio nal statements , but here no attempt is made to gen
encou nter, the achievemen t of engagement rather than
eral ize b eyo n d the prac tice o f the in di vi d u a l or g roup
d etach ment' . The abi l i ty to p l a c e th e c l i nica l p r o b le m
who have ge ne r a ted t h a t kn ow l edge .
w i thin the pa tien t 's world and to design personal ized
Pe rso n a l knowled ge is accrued fro m l i fe experi
care a n d i n terve n ti o n s t h a t take the pati e n t ' s experi
ences, such as rel a t i o n s h i ps and c u l t u r a l i n ll u e n ces
ence i n to
that c o n tribute to s h a p i n g i nd i v i d u a l pe r sp e cti ve s : as
ences as a key e l e m e n t of exper tise that develops from
a cco u n t
i s recognized across th e health sci
suc h , i t i n ll u e n ces p e rs o n a l in t er a c t ions, p e r s o n a l
clinica l prac tice experience (Benner. 1 9 8 4 : B u rke and
values a n d b e l i e fs . This k n owledge. i n its general
DePoy. 1 9 9 1 : Crepea u , 1 9 9 ] ; Jensen et a l . . 1 9 9 2 :
form. can be gained , as with professi o n a l cra ft kn ow
Jones e t a l . . 2 0 0 2 ) .
le dge , through soci a l i zation i n to a socie ty, g ro u p or
profeS S i o n a l
co m m u n i
t y. In i ts partic u l ar form, per
An
imp o rt a n t
consid erat i o n
in
u n d ersta n d i n g
practice knowledge is to reco gnize i ts c h a nging con
s o n a l knowl edge is perhaps acq u i red more con
teA1:. Beyond long-u nd erstood ideas of the knowledge
sciously by rellec t i n g upon one's knowi n g , bei ng, doing
exp l o s i o n , we n ow face kno w l edge issues l i nked to
a n d fee l i n g in each un ique s it u atio n .
gl obal reca sting of the boundaries of m a ny aspects of
Practi tioners u se a l l th ree fo rms of kn owle dg e i n
l ife, i ncl u d i ng the s tate, em p l oy m e n t , prac tice and the
practice . Proposi t i o n a l knowl edge can provide the
n a ture or lmowledge i t sel f. Ed wards and Usher ( 1 9 9 8 )
basis fo r u nde rsta n d i n g the medica l , psychosoci al a n d
considered the role pl ayed by g l o b a l izat i o n in reshap
c u l t u r al c o n text and t h e p hy si c a l and psychosocial
i ng know ledge, and t h e i m p l ications fo r a d u l t learn
n a tu re of the cl ient's n eeds a nd proble ms. In rela tion
ing. They argued that g l o b a l iza ti o n b r i ngs abou t a
to clinical reaso n i n g . practitioners need to accumu l a te
h e i g h te ne d sense of the wo rld as o n e p l ace with u n i
a n d u p d a t e c a refu l l y a rich a nd depend able knowledge
vers al knowledge, b u t paradoxically i t a l so en h a nces
base. to appra ise critica l ly the sa l ience a n d ap plicab i l
t h e sense of the l oc a l . the relative a n d the particu l ar in
i ty of such k nowledge to a part ic u l a r case, a n d to b e
our u ndersta n d i n g . These o bs er v a t i o n s have impl ica
v i g i l a n t in c heck i n g for potent i a l errors i n t h e cur
tions both for t h e n a t u re of the k n ow l ed ge we wou ld
rency a n d use of t h i s k n o w l edg e . par tic u l ar ly w he n
seek to learn and for t h e l ea r n i n g expe riences that are
ma ki ng importa n t d ecisions of d i a gnosis, treatment
needed to gain both glo b a l and local u ndersta ndi ng.
and prognosis. Professional craft knowledge enables
This s ame globa l ization is occ u r r i n g within the he at h
practitioners to t a i l o r cl i n ical decision maki n g i n
professions a nd w i t h i n the spec ia l i ze d world of man
recogn i t i o n o f the i n d iv i d u a l client's needs ( Rew a nd
u a l t h e r a py. The cases presented i n Sec tio n 2, by
Bar row, 1 9 8 7 ) . Such kn owledge e n a bles c l i nicians to
a u thors from a ro u n d the world, rellect the growing
p l a n , modify a nd critique their tre a tments to consoli
challenge facing tod a y ' s prac titioners to c r i ti q u e a nd
date their u n derstanding o f the par ticular c linical
b roaden their pers pectives .
p rob l e m Qensen et a1 . . 1 9 9 2 ) and to implement sou n d . eflkient a n d time l y deci s i o n making. Researc h has demonstrated that it i s the a b il i ty of experienced pro
W h at is the context of learn i ng?
fess i o n a l s to integrate propositional lm owledge wi th professional cra ft knowledge that enables them to
The education of health profess ionals occurs within a
assess the relev a nce of clin ical d a ta and to d i s t in g U i s h
b road context of profess i o n a l socializati o n . In s pecific
the significance of cruci al c u es
terms, the co n te x t of l e a r n i n g is the pa rtic u l a r learn
(D rey fu s and Dreyfus, 1 9 8 6 ; Elstein et al . . 1 9 9 0 : Larkin
ing s i tu atio n , wi th its cul tura l , h i s toric a l , soci a l and
et aI. , 1 9 8 0 ; Pay to n , 1 9 8 5 ) . Heal th profeSSionals draw
task d i m e n s i o n s .
and com prehend
o n their pro feSSional cra ft knowledge and their per so n a l k n o w l edge to i n te r a c t effectively w i t h patients and carers. S u c h kn owledge, co m b i ned with skills
• Professional socialization
in commu n i cati o n , list e n i n g and p r o bl e m solv i n g ,
Health p r o fess i o n a l education occurs before and a fter
fac i l i tates
g rad u ation as p a r t of the process of soc i a l ization or
interpersonal
i n teraction s
and
e n a b les
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25 E D U CAT I O N A L T H E O RY A N D PRI N C I PLES R E LATE D TO LEA R N I N G C L I N I C A L REAS O N I N G
the fin d i n g ( B e r l i n er. 1 9 8 8 : Dreyfus 1 9 8 6 ) ' th a t ex perts do not operate by
i n d u c t i o n i n to t h e profession . I n t h is process . t h e i ndi
acce p t a n c e of
vidu a l ga i n s a professio n a l identi ty. develops profes
and Drey fus.
siona l values/behaviours a nd gains the c a p a c i ty
fo l l o w i n g r u les derived fro m h i g he r-ord e r k n owl edge
to perfo r m effective ly as a mem ber of t h e profes s i o n .
b u t rath e r. by u s i n g comp lex s i t u atio n Cl l u n der s t a n d
Socia l iz a t ion i n to a profeSSion bri ngs w i t h i t t h e priv
i n g . a m a t u re and prac tised d exter i ty w h i c h comes
i lege and respo n s i bi l i ty o f a u tonomy ( o r i ndependent
from their breadth and depth of experience ' . Relati n g
deci s i o n making a n d a c ti o n ) . a sense o r d edication or
t h i s i ns i g h t to t he pre v i o u s d iscussion o f kn owledge.
c a l l i n g to t h e profess i o n a l fi e l d . the practice o f u s i n g
it is evident that ex perts use a com b i n a tion of both
t h e profess ion a l orga nization o r c o m m u n ity as a re f
propos i t i o n a l a n d n o n - propositional k n ow ledge.
ere nce. bel ief in the i n d i spensabi lity of the profession .
Situated theorists propose thClt lear n i n g is SOcially
bel ief in col legia l contro l . com m u n i ty rat her t h a n
conslT ucted .
self-i n terest. recog n i ti o n b y t h e p u b l i c . i nvo l ve m e n t i n
pa tients a W(e ) is fac i l i ta ted through shared interaction.
Such
learning ( by
practitioners
a nd
professi o n al c u I lure a n d mem bers h i p i n the p r o fes
common
s i o n a l assoc iation (Ha l l . 1 % 8 : R i tzer. 1 9 7 1 ) . T h e
collaboration a n d n egotiation o f me anings
capac i ty to reason e ffec t ive ly a n d pro feSS i o n a l ly is t h e
spectives. The situ ated lea r n i ng environment can be
key t o draw i n g toge t h e r a l l t h e s e a reas o f res p o n s i b i l
described as a co m m u n i ty o f practice ( Lave a n d
l a n g uage.
s h a re d socioc u ltural co ntex t .
or per
ity a nd priv i l e ge. Manu a l t h erapists occupy profes
Wen ger. 1 9 9 1 ) i n w h i c h lea rn ers a re cognitive appren
s i o n a l subgroups w i t h i n t h eir respec t i ve profess ions .
tices (Brown et a l . . 1 9 8 9 ). Learners benefit from ' i m ita
W h i l e t h e i r a pproac hes a n d pra c t i ce p h i l os o p h ies d i l'
tion C1 n d practice i n cooperCltive. a u t h e n t i c act i v i ty '
fer across t h ese g r o u p s ,
( G i esel man et al.. 200(), p.
i c a l reaso n i n g is
a
as
i s e v i d e n t i n Sec t i o n 2 , c l i n
com m o n
denomin ator brid g i n g t h e
m o r e su perl1c i a l d i ffe ren ces i n v i e w po i n t a nd l i n k i n g
t h e broader profess io n a l respon s i b i l i ty, iden tity a n d pra c t ice o f ma n u a l therapy.
• S i tuated
e n ables l ear ners to: • ga i n motivat i o n a l s u p po r t • p a r tic ipClte i n s h ared t h in k i n g and expertise • e ngage i n connicts s t i m u l a t i n g fu rther
learn i ng
debate
• be exposed to d i fferen t models o f t h i n k i n g a n d
The theo r y of situ ated learn i n g ( arising from the work of Brown et a l . ( 1 9 8 9 ) . Lave and Wen ger ( 1 9 9 1 ) , Vygo tsky ( 1 9 7 8 ) a n d others) assu mes that knowledge is embedded within the con text where it is used . Learn ing is a fu nction o f the activity, context and cu ltu re i n which i t is situated . S i t u ated learning is commo n l y i ncidental
2 () 3 ) . Accord i n g L o Resnick
( 1 9 8 9 . c i ted in Giese l man et a l . . 2 0(0) . th i s process
and u n inte n tion a l rather than deliberate
learn ing str a tegies. Wi thin cl i n i c a l practice settin g s . prac ti tioners s ho u ld endeavo u r to maximize their le ar n i ng of cli nical rea s o n i n g skills a n d associ a te d knowled ge by creat i n g pra c t ice environmen ts and p u r s u i n g si tuate d l e a r n i n g activities. as described i n C h a p te r 2 6 .
(Lave , 1 9 % ) . Activ i ties that faci l i tate s ituated lear n i n g (McLe l l a n . 1 9 9 6) in c l u d e stories. renection . cogn itive
apprenticeship. collaboratio n . coac h in g , mu l tiple prac tice. articulation of lear n i n g skills and the use of tech nologies or tools to en hance learning. T h e l e a r n i n g prinCi ples u nderpi n n i n g this t heory (Lave. 1 9 9 6 ) are:
What are the goals of teac h i n g and learn i n g p rogram m es? Form a l health science learn i ng programmes and in for mal professional developme n t activities are in ll uenced
by trends i n education and by professiona l education
• knowled ge needs to b e pres e n ted and lear ned in an
goals. Five key areas o f learn ing theory a n d d iscou rse
a u thentic context ( i . e . i n settings a n d applicati o n s
c an be seen to a r ticu late the goa ls of health scien ces
t h a t wo u l d n o r m a l l y i nvolve tha t k nowled ge)
education :
• learn i n g
requ i res
social
i n teracti o n
a nd
co l l aboration . Cope et
• h u m a n istic • e m a n ci p a to r y a n d st uden t-centred e d u c a t i o n
al. ( 2 000 . p. 8 5 1 ) drew a t te n tion to the
• socia l respon s i b i l ity
con necti o n b e twee n s i t u a ted learn i n g an d profes
• becomi n g agents for c h a nge a nd problem solver s
s i o n a l d eve lopme n t . They n o ted t h a t t here is w id e
• le a r n i n g how to learn and lea r n i n g for c apabi l i ty.
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T H E O RY A N D D EV E LO P M E N T
• H u m an i sti c, e m an c i pato ry and
of self- a c t u a lization by
stude nt-ce ntred ed u cati on
F u n da me n tally. h u m a n i s t psychology ( w h i c h is the basis fo r h u m a n istic e d u c a t i o n ) i s concerned with the h u ma n i ty. i n d i v id u a l i ty a n d wor t h
of each person
( S pencer e t a l . . 1 9 9 2 ) . H u ma n i s t ic education begins w ith the assu mption that teac h i n g is fi rst and fore most a re la t i o n s h i p be tween teacher and s t u d e n t . w h i c h includes h u man behav iour. h u m a n mea n i n g s . a n d h uman u nderstand i n g s t h a t grow o u t of u n iqu ely hu m a n
experiences
(Read
a nd
S i mon .
1975).
H u m a n i s tic educa tion i s b u i l t aro u n d the pri n c i p le t h a t i n d iv i d u a l s g row thro u g h posi tive relations h i ps (Rogers. 1 9 8 3 ) . Roger s ' a s s u mptions about l e a rn i n g c a n be s u m m a rized a s fol l ows: • h u man be i n gs h ave
a
n a t u r a l capac i ty a n d desire
onment free fro m thre a t
l e a r n i ng is fa c i l itated whe n . as fa r a s p os s i b le . i t is self- i n i tiated and self-direc ted
• lea r n i ng t h a t i nvo l ves the whole person ( reel i n gs as
we l l as intel lect) is mor e l a s tin g and pervas ive . •
to c o n t ro l . the e l e men ts in the lea r n i n g e n v i ro n ment that relate to t h e i r needs . In h u m a n istic educatio n . l e a r ners a re gra n ted res ponsi bl e freedom and a re enco uraged and expected to become responsi ble fo r their learn i n g w i t hi n the fra mework for l ear n i ng p rov i ded by the teacher and the lear n i n g programme ( Tabl e 2 5 . 1 ) . S uc h education promotes the role o f teach ers as fac i l i ta tors of learn ing and s u ppo r ts the go a l o f hel p i ng students to learn how to lea r n a nd to become fu l ly fu n c t i o n i n g people. Thi s t h e me of e m powerment o f the i n d i v id u a l is i n herent in the tea c h i n g philosophy and practice of critic a I ped a gogy espoused by Freire ( 1 9 7 2 ) . Freire advocated
fo r l e ar n i n g • s i g n i ftca n t or mea n i ngful l e a r n i n g l a kes pl a ce w h e n the su bject m a t te r is pe rceived by s t u d e n ts a s rele v a n t to t h e ir need s . a s p i r a t i o ns a n d go a l s • lea r n i n g is acq uired and reta i ned b e s t i n a n env ir •
freedom controlling. o r h e l p i n g them
described as he l p i n g l e a r ners to achieve t h e
self-ev a l u a tion is va l uable as it promotes cre a t i v i ty. i ndependence and self-reliance
• t h e most socia l ly usefu l lear n i n g i s l e a r n i n g ab o u t
t h e process o f l e a r n ing . A s i g n i fi c a n t c o n t r i b u t i o n to h u ma n i s t i c education is
le a r n i n g as a process of beco m i n g aw a re of cl l1 d po l i tica l situation t h r o u g h problem
o n e ' s soc i a l
p o s i ng and d i a l ogue between te ac hers and students in s i t u a tions that reduce the power i m bal a nce between t hem ( Bu rn a rd . 1 9 9 5 ) . S u c h e d u c a t i o n seeks to l i ber ate people both soc ia l ly and po l i tic a l ly. Critical pedagogy is a mode of te a c h i n g o ften p u r sued i n con tempo rary educati o n . i n w h i c h students are given the oppo r t u n i ty to thi n k critica l ly about
the
l i m i ta t i o n s to t h e i r freedo m . thereby h e l p i n g them to le a r n to be free. The impor t a n ce of c ri ti c a l awareness h as a l s o been e m p h a sized by To rbert ( 1 9 7 8 ) and Me zi row ( l 9 8 5 a ) . To rbe r t ( 1 9 7 8 . p. 1 0 9 ) a r g ued t h a t increased awareness i s t h e key t o l i be r a t i n g ed u ca
a ttention than we bri n g to bear on o u r affa i rs ' . S uc h atten tion is necessa ry for the search [or s h a r e d pu rpose, t io n . It i nvolves ' a h igher q ua l i ty o f
ordi n a rily
sel f-d irection a nd h i g h -q u a l i ty wo r k . wh i c h ' cre a te
the concept o f a h i erarc hy of needs ( M a s low. 1 9 7 0 ) .
the poss i b i l i ty fo r a d u l t rel ated ness . i n te g ri ty. a n d
These needs . i n ascend i n g order. a r e phys iological
ge nerativ i ty a n d therefo re represent the essence o f
o r s u r v i v a l need s ; safe ty need s ; love. a ffection a nd
gen u i n e ly liberating h i g he r e d u c a t i o n ' ( Torbet. 1 9 7 8 .
b e l o n g i n g needs; es teem needs : a nd need for seH
p . l l O ) . To rber t ' s go a l s c a n b e re l a ted to the goa l s i n
actua l i z a ti o n . M a s l o w proposed a n u mber of pri n
t h e h e a lth-care i n dustry o f achiev i n g e ffect i ve team
c i ples o f operation fo r these need s . G r a t i fy i n g needs a t
wor k . autonomous professional be h av i o u r a nd sel f
e a c h l e vel ( s t a r t i n g w i t h t h e l o west) frees
d i recti o n . a n d q u a li ty assurance.
a
perso n for
g rati fi c a ti o n at higher leve l s : where a need has been
Accord i ng to Mezirow ( 1 9 8 5 a ) . the p romoti o n o f
s a tisfied . a person i s best a b le to de a l wi t h depriva
'critical awarenes s ' s h o u l d be a i med a t helping stu
tions o f that need in the fu t u r e ; he a l thy perso n s h ave
den ts to direc t t h e i r own l ea r n i n g . to l e a r n how to
had their basic need s met and are p r i n c i pa lly moti
make m e a n i n g out of their ex perience. a n d to iden t i fy
h i ghest possibil
v a l ues i n their l ives . Mezi row ' s ( 1 9 8 5 b ) criti c a l the
ities. I n h a r mony w i th these a rgume n ts . the a d u l t
ory of a d u l t learn i ng a nd e d u c a t i o n draws on the
vated by their needs to a c t u a l ize t h e i r
educator's r o l e ( with i n t h e context of t h e l e a rn in g sit
ideas o f the ph i l osopher-socio l ogist J u rgen Habermas
uation) i s to h e l p i ndivid uals to meet the i r more b a s i c
( 1 9 7 0 . 1 9 7 1 ) . Habe r m a s ' c r i t i c a l l e a r n i n g t heory
b e l o n g i n g ) a n d then t o h e l p t h e m t o
i d e n t i lles three d o m a i ns i n w h i c h h u ma n interest
ac h i eve t h e i r fu llest p o te n t i a l . T h is p rocess c o u ld b e
genera tes k now ledge . These are the tec h n ic a l . the
n e e d s ( e . g . safety.
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Table
25.1
E D U CAT I O N A L T H E O RY A N D P R I N C I PLES R E LAT E D TO LEARN I N G C L I N I CAL R EA SO N I N G Characteristics o f h u manistic, learner-cen tred learning progra mmes
M aslow
Knowles
Rogers
Empath i c l isten ing Students share responsibility with the faci l i tator for the content and direction of the course The abil ity to self-evaluate is an important part of education Differences among students a re expected and respected I nstructor criticism must be constructive and meaningfu l
Learning involves col laboration between a facil itator and student Learners move from a pos ition of depende ncy u pon the teacher to one of self-d i rection The increasing store of experience held by adult learners provides a profound resou rce fo r learning for themse lves and others The need to cope with real-l ife situations provides the sti mulus for learning Teachers a re respons i ble fo r creating conditions and p rovid i ng tools to help students to dis cover the i r need to know Education progra mmes should be designed acco rd i ng to students' a b i l i ties and needs The goal of education i s to build increased competence for stude nts so they can reach their fu l lest potential i n l ife
A cli mate of trust in which cu riosity and the natu ral des i re to learn can be nourished and enhanced A partici patory mode of decision making i n all aspects of learn i ng, i n which students, teach ers and administrators each have a part Helping students to prize th emselves, to build their confidence and self-esteem U ncover i ng the excitement of i ntellectual and emotional d i scovery, which leads learners to become l ifelong learners Developing i n teachers the attitudes that researc h has shown to be most effective i n fac i l i tati ng learning Helping teachers to grow as people, fi n d i ng rich satisfaction i n the i r i nteraction with learners An awareness that the good life i s with i n , not someth i ng that is dependent on outside sou rces
Derived fro m Knowles
(1 980), Maslow (1 970), Rogers (1 983).
pract i ca l and the e m a n c i p a tory doma i n s . These t h r ee
l e a r n e r is t h e centre o f t h e l e a r n i n g prog r a m m e , n o t
' ways o f k n o w i n g ' can be described as t he ' e m p i r i c a l
o n ly a s t h e pri n c i p a l fo c u s o f the le a rn i n g b u t a lso a s
a n a ly t ic (sciences) a pproach ' , w i t h t h e go a l o f estab
a n active par ticipa n t i n s h a p i n g t h e le a r n i n g pro
l is h i n g c a u s a l i ty ;
gra mme t hr o u g h setti n g go a l s a n d p l a n ni n g lear n in g
t he
' c o m m u n ic a t i ve
actio n '
or
' h istor i c a l - hermeneutic ( sc i e nces) approa ch ' , which
activities and assessme n t . T h e te a c he r a c t s as
seeks i n terpre t a t i o n a nd ex p la n a t i o n of i n d iv i d u a l
tator a n d g u i d e rather t h a n a n i ns tructor. Tab l e 2 S . l
experien ces a n d perspect ives ; a nd t h e ' e m a n c i patory
i l l u strates t h is a ppro a c h .
a
fa c i l i
act i o n a p p roac h ' , w h i c h i nvo l ves an i n terest i n s e lJ k n o w l edge. S u ch e m a n C i p a tion frees u s from fo rces ( e . g . e n v i r o n me n ta l fo rces) that l i m i t our o p t i o n s a n d con t ro l over o u r l i ves . rde n ti fi c a t i o n of t h es e three ways o f k n ow i n g s u pports the c o n te n t i o n t h a t m a n u a l therapists m u s t b e able to d r a w on t h e fu l l spec tr u m of avai l a ble evidence ( rese a rc h and ex perien ce based ) to g u id e t h e i r c l i n ica l dec i s i o n s a n d acti o n s .
• Social
respo n s i b i l i ty
The c h a n ges i n h e a l th-care a n d pro feS S i o n a l practice ( i n c l u d i n g manual therapy) have a n u m ber of i m p l i c a t i o n s for t he ed u c ati o n o f beg i n n i n g p r a c t i t i oners ( H i ggs et a I . , 1 9 9 9 ) . These i n c l u d e the need to:
St uden t-cen tred l e a rn i n g is l i n ked t o h u m a n i s m ,
• educ ate health sc ience s t u d e n ts for t h e i r role i n the
emanci patory and ad u l t l e a rn i n g . T h i s ap proac h to
political arena o f hea lth and health care, remem
l e ar n i n g focu sses on the h u m a n res o u rces poten tial
beri n g that kn o w l ed ge o f the pol i t i c a l system i s
o f learners, seeki n g to provide l e a rners w i t h t h e tools
i m p orta n t i f people a r e to b e effective i n i n ll u e n
needed to learn th rou g h o u t l i fe, to be ab le to adapt to
c i n g p o l icy resou rce a l l o c a t i o n ( G a rd n e r, 1 9 9 5 )
new circ u m s t a nces a n d to be proac tive in a d dres s i n g
• conv i n c e stud ents that it i s relev a n t to their educa
t he i r need s fo r learn i ng , c ha n ge a n d a c ti o n . The
tion to l e a r n ' how the wo rld wo rks ' ; this i nvo lves
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T H E O RY A N D D EV E LO P M E N T
notions o f how pol itics, eco n o my and e n v i ronment
change. In order to prod uce conv i ncing and successful
i n teract, notions t h at for many yea r s were tho u g h t
cha nge agents, education al programmes need to help
t o be
outside t h e p u r v iew
of profession a l education
students to work within the real i ty o f the workplace. not trampl irlg b l i ndly. na ively or ar roga n tly o n existing
re l a ted to health • socia lize s t u d e n ts for a new approach to pro fession
a l i s m ; fo r d octors. n urses and a l l ied health profes
health
h ard-won progress or til tirlg
futilely
at the windmills of
intransigent bureau cracy. beconling disillusioned in the
' asks whe ther
process. Instead . change agents work w i t h people and
health c a re is somethi n g we d o for people o r some
sy stems to understand the status q uo and facili tate
th i n g we do with the m ' (Lawson et al. . 1 9 9 6 , p. 11 ;
achievable shared goals and actions for c ha nge.
s i o n a l s . the c h a ng i n g view of
ita l ic s added ) .
Engel
( 2 000)
argued that the hea lth profess ions
• prepare students fo r a b roader r o l e th a n s i mply
should take the lead i n p re p ari ng fu tu re g ra duates to
that o f the competent begi n n i n g practiti o n e r i n a
adapt to the impending changes of the 2 1 s t century
c l i n i c a l s e n s e : we need to e d u c a te t h e m for soc i a l
and to par tici pate in the man ()gemen t of c hange. A
respon s i b i l i ty.
model of hea lth practitio ners as ' i n teractional profes
Prosser ( 1 9 9 5 ) con tended that leclrners s hou ld l earn someth i n g about their fu ture respo nsib ility to the com mu n ity at l arge. [-Ie argued that lear n i n g is in ll uen ced many ways by the teacher's choices
and
in
()clions. These
i m pact on hea l th science education prog rammes i n sev era l ways : students observe their (posi tive and nega tive) role model s : learn ing goa ls , content and assessment can focus
simply
o n technicaJ aspects of the professional
role o r c a n more broadly encompass discussion about issues o f commmlity interest; more comprehensive i n terpretation and debate of ethicaJ practices can include not j u s t the irldivid uaJ client's medical needs but also m a tters of responsibility to society.
Hill
( 1 9 9 4 ) fur
ther conte n ded th a t edu c a ti o n must embrace and pro m o te soc i al j ustice a s a pri ncipal educationa I imperalive. remin iscent of Freire 's vision of humanity and soc i a l improvement. In the con text of manual thera py. as dis cu ssed in Chapter
1.
c linical reasoning is not
limited to
pathol ogy and technical m anage Con temporary ma n u a l the rapists must be able to
d ecisions regardi n g men t .
make both di a g nostic and n on diagnostic decisions. -
Through skUled narrative reasoning they can acqu ire an u n ders tanding of the patient s ind ivid u a l experience '
and the basis for the palient's perspectives . This u nder st a nd ing enab l es therap ists to act as effective advocates for sociaJ j u s tice irl a heaJth system where attention to j u s tice a nd rights of
ind ividuaJs
often su ffer a t the
expense of economic ration alism .
siona l s ' ( H iggs and Hu n t . 1 9 9 9 ) has been d evel oped to a d d ress t hese ex pectat ion s It is loc ated wit h i n a model .
of social ecology. Social ecol ogy dea ls with i n lerac tivity a mong people a n d between people and their environ ment;
it a c k n ow ledges the
i m portance o f
basing
behav iou r on promot i n g optinla l . suppor tive re l a tion ships between h u m a nity. comm u n i ty and the environ ment. The characteri stics o f i n teracti o n a l profession als are g i ve n i n Ta b l e 2 5 . 2 . These capaci ties w i l l enable practitioners to act
in
a competent professio n a l man
ner and to engage in effective reaso n i n g . coll abora tive problem solvi n g . critical sel f-ev a l u a t i o n . life long learn in g an d pro fessional review and d evelopme n t .
• Learn i n g
how t o l earn
Helping students lea r n how to le arn is a n impor ta nt goa l in
hea lth sciences education.
The
l itera ture
presen ts () ra nge of approa c h es for t h i s . T hese i n c l ude i n d i v i d u a l study g u ides. i n d i v i d u a l t u i t i o n . s peci al teaching ski l ls s u bjects
and
i n tegrated curricu l u m
' a ctions' ai med at imp roving students ' lear n in g Such .
prog r a mmes i n creasingly recog n i ze the i m portance of e n h a nCing students' awareness of and con trol over their learning processes , r a ther th a n j ust teac h ing them l e a r n i n g skills (Ma r t i n a nd Ramsde n , 1 9 8 6 ) . It is desira ble for students to become aware of their learn ing style/a ppro a c h options. to develop their ab i l i ty to u se e ffective le a r n i n g strategies. and to t a ke responsi
• Beco m i n g agen ts fo r c h an ge an d
bility
for m anag i n g their a pproaches to learning.
G i b bs
( 2 000)
arg ued t ha t o n e way o f improv ing
the
ability to learn is to u n dersta n d the lear n i n g process .
p robl e m solvers
Approaches to le ar n i n g are presented below. In add
to
To meet current and future expectatio n s of the profes
ition
sionaJ workplace, practitio ners need the abi l i ty to irlter
to l ose s i g ht of the m a i n pu rpose of lear ni ng, as
learn in g to lea r n . however. it i s importa n t not
is,
articu l a ted by Ramsden ( 1 9 8 6 ) . which is to learn
they need to be ab le to be pro b lem solvers a n d agen ts for
o r c h a n ge one's co nceptio ns about the co n tent at a
act with and change the con text of practice. That
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Tab l e 2 5 . 2
E D U CAT I O N A L TH EORY A N D P R I N C I PLES R E LAT E D TO LEAR N I N G C L I N I C A L R E ASON I N G Characteristics o f i nteractional professionals
Feature
C haracteristics
Competence
Technical competence (discipline-specific) and generic skills (incl u d i ng skills i n commun ication, eval uation a n d investigation, se lf-di rected learn i ng, interpersonal i nteraction and cultura l competence) Competence in reflective practice and critical self-evaluation Competence in problem solving and clin ical reasoning Demonstrated characteristics a n d behaviours of members of professions, including professional ism and responsibil i ty for one's professional decisions and actions The capacity to demonstrate responsibility in serving and enhancing SOciety The ability to inte ract effectively with people and environment and to change the context of p ractice The capacity to p rovide s i tuationally relevant leaders h i p
Refl ection Problem solving Professionalism Social responsibility Interactivity and change agency Situational leadership Based
on
Higgs and Hunt (1 999).
releva nt level (e.g. l e a r n i ng
that is oriented to gr ad u a te practice-based matters) within t he context i n wh i c h one is lear n i n g ( e . g . he a l th care. m a n u al therapy) .
• Learn i n g fo r capab i l i ty
�
-
..
- -
: Who are the learn e rs? What d iffe rence does it make?
Lear ner c h a r a cteri st i c s and styles are i m p or ta n t c o n
the design and im pl em e n tati o n of learning programmes .
Siderations i n
Hea l t h pro fess i o n a l s are competence. C a pa bi l i t y
ex p e ct ed to d e m o ns tr a te is a broader c on c e pt t h a n
-
compete nce a n d i s concerned with the ab i l i ty to per form
effect i ve ly.
p arti c u l arly in the here-and-now (S tep h e nso n, 1 9 9 8 . p. 3 ) : ' Capability embraces compe tence but is also forward-looking, co ncer ned with the realization of pote ntia l . A capability approach focu sses on t he capacity of individ uals to par t icip ate in the for mulation of their own developmen tal n ee d s and th o se of the context in whi c h they work and l ive ' . A ca p a b ility appro ach is developmental , self-directed and involves learners managing their own le a r ni n g . Capabili ty im pU e s being able to look a head a n d a c t accordin gly in a changing world . Capability exists ( S tep he nso n , 1 9 9 2 ) when p e op le , with j u s tified confIdence, are able to: • t ake ef fec tive
a n d a p pro p ria te a c tio n expl a i n wh a t th ey a re about • live a nd work effectively w ith other people • c o n t i nu e to learn from their i n d iv i d u a l ex perience and their experiences with o thers i n a d iverse and c h a n g i n g s o cie ty. •
• Learn i n g sty l e s 'The qual ity o f student lea r n i n g depends on the stu a pproa c h to le ar n i n g ' (Rcillls den , 1 9 8 5 , p. 5 2 ) . Rese arc h concern i n g learning sty les has emp h as i z e d the fm ding that learners' responses vary w ith the ways in wh ic h l e ar n i n g is o ffe r e d and the learning e n v iro n ment is c re a ted . Sludents ' learni n g styles are a lso s trongly inlluenced by their past learn ing experience and their perceptions of their learnin g situation (Prosser and Trigwel l, 1 9 9 8 ) . Teac h e r s , th erefore, need to co n s id e r the effects that t he t e a c h i n g method and setting have on their s tuden ts ' lea r n i n g . Knowl edge and effective use o f l earnin g sty les are als o important in that teachers can facilitate students' a doptio n o f dent's
more effective lear n ing s tyles ( e . g . deep learning) and of le arn in g a p pr o a ch es more suited to the
task. Fur t her, can
discussion of lear n ers ' a ppr o a c h es to lear n in g result i n
s tudents de vel o pin g more e ffective strate g ies
for lifelong lear n i n g a nd acqu irin g greater success in
the use of metacogni tive le ar n in g or l e ar n i ng that actively in vo l ves critical self-a ppra is a l . F o r self-dire c ted These actions req u i re sel f-knowledge, self-aware ness, learners ( e . g . manu al therapy practitioners) , it is usefu l se l f- c o n ltde n c e , se l f-c ritiq ue a nd the capacity to work t o Imow how t o lear n a n d how t o learn more e ffective l y. e ffe cti vely with others . These are characteris tics that Th ree of th es e lea r n i n g styles models are d e scri b e d are i n herent in ski l led c l i nical reasoning a nd expected i n Table 2 5 . 3 . of c a p a b l e . a u tonomous health p ro feSSio n a ls . Copyrighted Material
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Table 25.3
Learning styles
M odel
Style
Characte ristics
H o n ey and M u mford (1 982)
Activist
Open minded. concerned with the here and now. enthusiastic about n ew th ings. fi l l ed with activity. l i kes crises. l i kes brai nstorming. thrives on c h a l l e nge. gregarious. likes new experien ces
Reflector
l i kes to ponder on things. l i kes to stand back and view events. cautious and thorough. l i kes to 'sleep on it'. takes a back seat. keeps a low profile
Theorist
Logica l . step- by-step approach. rati onal. concerned with basic concepts. detached a n d analytical. l i kes to analyse and synthesize
P ragmatist
Practical. l i kes to try out th eories and i d eas. acts q u ickly. l i kes p roblem solvi ng. l i kes new ideas. l i kes to get on with th i ngs
Ko l b (1 984)
Converge r
Relies primarily on active experi mentation and abstract conceptual ization. Strength lies in problem solving. decision making a n d the practical appl ication of ideas. Knowl edge o rganizati o n favou rs hypothetical deductive reaso n i ng. Prefer dealing with tasks and prob lems rather than social and i nterpersonal issues
Diverge r
Rel i es primarily o n concrete experience and refl ective obse rvation. Strength l i es in imagi native a b i l ity and awa reness of m ea n i n g and val u es. Concrete situations are viewed from many perspectives orga n ized i n to
a
meaningful
'gestalt'. Pe rforms best in situations cal l i ng for generati on of alternative ideas and i m p l i cations. I nte rested in people and tends to be i magi native and fee l i ng oriented Ass i m i l ator
Rel ies primarily on abstract conceptual ization and reflective observation. Strength l i es in inductive reasoning and the abil ity to c reate theoretical models. assi m i lating dispa rate observations i nto an i ntegrated exp lanation. Less focussed on people and more concerned with ideas and abstract concepts
Accommodator
Relies primarily on concrete experience and active expe rimentati on. Strength l ies in doing th i ngs. carrying out plans and becomi ng i nvolved i n new expe ri ences. Best able to adapt to changing ci rcu mstances as oppo rtu n ity seekers and risk take rs. Tends to solve probl ems in an intu itive. trial-and-e rror manner. relying heavily on other people fo r i nfo rmation rathe r than the i r own analytical abil ity. At ease with people
Entwistl e and Ramsden (1 983)
Mean i ng o rientation
Active . deep learning approach to constructing personal
Repro d u c i ng
Similar to su rface learn i ng. with an emphasis o n rote
mea n i ng. which i nvolves i ntri nsic motivation orientation
learning and res ponding to extri n s i c motivation
Strategic orientation
A i m i ng at good results; s i m i l a r to Biggs (1 987) concept of ach ieving dimension
N o n -academic
Lack of i n terest i n or concern for acad emic res ults
orientation
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25 E D U C AT I O N A L T H E O RY A N D P R I N C I P L E S R E L AT E D TO L E A R N I N G C L I N I C A L REASO N I N G
Honey and Mumford ( 1 9 8 2 ) identified four learning styles. activist. reflector. theorist and pragmatist. and fou nd that people commonly have elements of all four styles. • Kolb ( 1 9 8 4 . p. 3 8 ) regarded learning as ' a process whereby knowledge is created through the trans formation of experience ' . He described four basic forms of knowing . divergence. assimilati o n . con vergence and accommod atio n . and argued that a major i n fluence on i n d ividual learning styles is the u nderly i ng struc t u re of the l earning process . He demonstrated that effective and skil led learning encompasses clemen ts of these fou r approaches. • Entwistle and Ra msden ( 1 9 8 3 ) examined general tendencies/approaches to learning and attitudes to studying and identified four study orientations: meaning orientation. reproducing orientation. stra tegic orientation and non-academic orientation. •
Ramsden ( 1 9 8 8 . p. 2 0 ) described the dee p (or mean i ng orientation) and surface (or reproducing orienta tion) approaches to learni n g as follows: Deep approaches exemplify the type of learning that employers and teachers expect students to demonstrate. Only through usi ng these approaches can students ga in mastery of con cepts a nd a firm hold on detailed factual know led ge in a given subject area. Such approaches embody the imaginative and adaptive skills and wide sphere of interests that are increasingly demanded in the world of work. In acute con trast surface approaches epitomise low-quality learning. are geared to short-term requirements. and focus on the need faithfully to reproduce fragments of information presented in class or tex tbooks . . , surface approaches are concerned with ' getting the right answer' to the exclusion o f knowing how to get it and of what i t means when it has been obtained . The deep lear n i ng a pproach reflects the goals of hea l t h science education . including a commitment to lifelong learning, accoun tabiUty of practice and crit ical self-eval u ation. These o utcomes are preferable to outcomes that reflect surface learning approaches, such as a preference for fo llowing rules. responding only to direct supervisio n . and reliance on evaluation by others. Health care is a n inexact science. and deep a pproaches to lear ning are entwined with other prac tices of the hea l t h professional. includ ing exercising
profeSSional j udgment a nd making clinical decisions i n an arena often characterized by uncertainty. com plexity and multiple alternative action choices.
• Learn e r d e m ograp h i c s If w e a r e aiming t o facilitate learner-centred adult learning. we need to know who our learners are. This knowledge enables teachers to match planned learn ing goals with lear n er characteristics. Factors that could be considered in seek i n g to understand a learn ing group include. first. contextu a l factors . such as programme leve l , location and mode: these g ive gUid ance as to learner motivations and expectations. Secondly. teachers can assess student profile factors. including enro llment numbers. age. gender. educa tional b ackground. socioeconomic cha racteristics and cultural situation . To create a n optimal learn ing e nvironment to encourage adult, deep, a n d self directed learning requires consideration of learners' task maturity ( Higgs. 1 9 9 3 ) . which encompasses their preparation for and rea d iness to engage in the current learning task. and the creation of pro grammes that l iberate self-directed ness and learner responsibility.
H ow do learners l earn? Learners learn in many ways . However. it is most use ful to look at several key learning theories or move ments. which can help us to understand both how different learners learn and how we could help learn ers to learn more effective ly, and be better learners ourselves . This section focusses on adu l t learning, experien tial learning, and the interaction between assessment and learning. It is impor tan t to remember that adult lear ning is an approach to learning. Adults. particularly those strongly schooled i n rote lear n ing approaches, may need to learn to become adult learn ers. They may need to learn how to be self-directed , to be responsible partners in learning p rogrammes. to be self-evaluative and to set and pursue their own learni n g goa ls.
• Ad u l t l earn i n g Adult learning is a common a n d popular aspect of teaching and learning today. The foundations of adult learning theory are key assumptions (supported
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b y subsequent researc h ) m a d e a b o u t ad u l t l e arners ( as c i ted i n Knowles e t aJ . , 1 9 9 8 ) :
a ndragogy) school: freedom from the restrictiol1s
• ad u lts become ready t o le a r n the th i ngs they need
to k n ow and be able to
do in order to cope effect
i vely with the i r rea l-l i Ce situati ons: there for e , these a re the a ppropri a te starting points fo r organ i z i n g a d u l t l e a r n i n g a ctiv i ties
orienta tion to lea r n i ng , adu lts are life -cen tre d (or task/
• i n c o n trast to c h i ld rens' s u bj e ct - cen t r ed
problem-cen tred ) i n t h ei r learning orientation : th erefore, the appropri a te u n i ts for organizing a d u l t lear n i n g are l i fe s i t uations, not su bj ec t s • a d u l ts come i nto a n educat i o n a l ac t i v ity w i th a
greater vol u m e and a different q u ali ty of experi ence t h a n yo ung peo p l e ; expe rience is the richest resource for a d u lts ' l e a r n i n g and, therefore. the core methodology o f adult educa tion i s the a n a ly sis o f experience • adults have
a
deep need to be se l f- d i rect i n g : there
fo re, the role of the teacher is to e n gage
Self-directed learn illg alld the adult lea rn i ng (or
i n a process
of m u t u a l i nq u i ry with them rather than to tra ns mit k nowledge to t h em and t h e n evaluate their conform i ty to it • i n divi d u a l d i fferences among people i n c rease with
age: the refore, ad u l t education must m a ke optimal prov i s i o n fo r d i fferences i n style, t i m e, place a nd pace of le a r n i n g • adults n eed to know why they n e e d to l e a r n some
t h i n g b e fore u n de r tak i n g to lea r n it • ad u l ts h ave a sel f-concept of being respo n s i b le for
their own decisio n s a n d lives • wh il e adu l ts are responsive to some external motiv
ators ( e . g . j obs ) , the most potent motivators a re i n te r n a l pressures ( e . g . the desire for i ncreased self estee m , j o b satisfa c t i o n such as s uccess in pa tie n t
ma n a gemen t , q u a l i ty o f l i fe ) .
of teache rs/freedom as lea rn e rs.
'This a p pro a c h
pl aces the u n i q ue goals of individ u al learners as
and provides a StTuc h ieve their own ends'
ce ntral in the lear n ing process ture to assist learners to
ac
(Boud , 1 9 8 7 , p. 2 2 4 ) . A cco r di ng to Boud , this a p proac h i s most su i table for situations where l earn ers are able to i d en ti fy and articu late their lear n in g needs and go al s and where appropriate resources are avail able. The l e a r n i n g contract approach of Knowles et
al. ( 1 9 9 8 ) i s typical of this traditio n . aw h u m a n istic edu
Learner-centred education and cators : Jreedom to learn .
This approach foc u sses
on the facili tati o n of l e a r ni n g by
a non-di rective
fac i l i tator w i th i n a h i g h ly suppor tive, accepting a n d respectfu l environmen t . This i s
typic a l o f the
tra d i ti o n of Carl Rogers ( 1 9 6 9 ) . Lea r n i n g is seen to be a n acti v i ty that should i nvolve the whole per s o n . i nc l u d i ng attitudes. v a l u e s . and emotions as we l l as cogni tive a nd p s yc h om o tor a spects. There is also the recog n i ti o n t h a t l e a r n ers may be i n h i b i te d from l ear n i n g by past experie nces and emotio n s , a n d t h a t p a r t o f the teac her's role i s t o li berate learners fro m s u c h in hib i ti ng facto r s , thereby pro vid i n g them with freed o m to l e a r n . Critical pedagogy a n d social actioll : freedom t h rough learnillg.
While the prev i o us three approa c h es
pos i t i o n lea r n i n g as an i n d i v i d u a l p henomeno n . accord i n g t o this approach le ar n i n g i s a social phenome n o n i n which learners not only
learn in
a g r o u p b u t have respo n s i bility for o t her lear ners . S upporters of this a pproach ( e . g . Freire, 1 9 7 2 ,
1 9 7 3 ) see l e arning a s a means o f free i ng people, u s ing l ear n i n g as a way of remov i n g the l i mits that lack of knowledge pl aces upon people, an d en cour a g i n g them to tal<e p a r t in sh a pi n g the society i n
The p h i l osophy and practice o f ad ult learning h a s been i n fl uenced by n u merous individuals and gro ups . Boud
( 1 9 8 7 ) categorized ad u lt learning into fo ur tradi t io ns . Train ing and efficiency in lea rning: freedom from dis-
wh i c h they li ve . Boud ( 1 9 8 7 , p. 2 2 8 ) con tended t h a t each of these approa c hes ' m ay be a v a l i d response to a given a d u l t lear ning need ' . E a c h a p p r o a c h has strengths and
This approach re gards teach
weaknesses , but all four have two common el ements:
ing an d lear n i n g as a technology. ' O nce a learner has
respect for le arners and their experience and the need
decided to st u dy a particular topic or to lear n new
to commence with the learner's present
skills. the aim of practitioners of t his a p pr o ach is to
i n g . A m os t i n teresti ng aspect o f B o u d ' s categoriza
traction ill leamillg.
u ndersta n d
mal(e this task as strai gh tforward as possi ble and to
tion is the strong theme of freedom used to h i g h l i g h t
ensure th a t all l e ar n in g is di.rected effic iently towards
e a c h appro a c h .
this e nd ' (Boud . 1 9 8 7 , p. 2 2 3 ) . This approach arises out of the progranuned learn ing tradi tion .
N u merous authors have reported their experiences and hypotheses concer n i n g condi tions that faci litate
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Table 2 5 . 4
E D U CATI O N A L T H E O RY AN D PR I N C I PLES RE LATED TO LEAR N I N G CLI N I CA L R EASO N I N G A d u l t learn i ng conditions a n d behaviours
Environme ntal cond iti o n s
Decision-maki ng/managem e n t
Ad u l t learn i n g behavi o u rs
factors
M otivation Acceptance of learner as person Freedom/autonomy I ndividuality Emphasis on abilities/experience Student-centred learning Resource-rich environment Mutual respect/trust Teacher support/facilitation Learning via experience re levant to learner Praxis: integrati ng reflection, theory, experience Interaction between learners Effective/appropriate group dynamics Security/support From Terry and
Problem-solving Interaction with teacher and other learners Active participation in learning Experiential learn ing Self-co rrection I n terdependence Critical reflection Progressive mastery Active seeking of meaning Individual paci ng Empowered self-direction practice Enthusiasm fo r learning Reciprocal learning I nternal d rive/motivation
Shared goals Shared management Mutual decision making/ planning Shared reso u rce acquisition Learner involvement i n learn i ng, needs diagnosis, and eval uation Learner d i rection i n posi ng questions/ seeking answers Effective co mmunication Choice in partici pation Col laborative facil itation Ongoing review by teacher and learners Learner identification of community goals and needs as part of own learning context Learner acceptance of responsibil ity fo r learning
H iggs (1 993).
adult learn i ng. These i nclude ' principles of teach ing' (Know les , 1 9 8 0 ) , ' maj or genera l izations' (Knox , 1 9 7 7 ) about how teachers can facilitate adult learn ing, princip les of elTective adult learning (Bagna U . 1 9 7 8 ) a n d the 'char ter for andragogy ' (Mezirow. 1 9 8 1 . 1 9 8 5 a . b) . which is based on the t heories of Habermas ( 1 9 7 1 ) . Mezirow proposed that teachers i n a d u l t learning need t o make important decisions and opera te accord i n g to values that give priority to the learner's developing autonomy. The work of these authors supports the fol lowi n g two propositions. First. a nu mber of accepted conditions for learning can be identified and these can be subdivided into environ mental condilions and conditions related to the decision making and management strategies employed in the programme (Tab l e 2 5 . 4 ) . Secondly, the role of the teacher in adu lt learning programmes is to create t hese conditions (with the learners) through manage ment of the learning programmes.
• Experie ntial
l earn i n g
How do learners experience their le a rni n g and make sense of it? The essence of experiential lea rning was
cha racterized by Boud and Pascoe ( 1 9 7 8 ; cited in B u r nard. 1 9 9 5 ) a s : • the i nvolvement of i n d ividual learn ers in their
l e a rning e n gaging t heir ful l attention .
• the correspondence of the l e a rni n g activity to the
outside world. emphasizing the qu a l ity of the learning ex perience rather than i ts location • a l lowi ng learners to h ave con trol over the learni n g experience s o t h a t they c a n i n tegrate it w i t h their own mode of operation i n the world and can experience the resu l ts of their decisions. This list has parallels with adult and humanistic educa tion. In addition , there is a n eed as Michelson ( 1 9 9 8 ) emph asized. to remember that learning through experi ence involves embodied kn owing as well as being a n experience o f t h e mi n d and a social ex perience. This is particu larly pertinent to fields such as ma n u a l therapy, which involve high levels of p hysical interaction in d ata collection and treatment, an d where manual ther apists often come to 'know through their fmgertips' . Boud and colleagues (Boud et al . , 1 9 8 5 ; Boud and Walker, 1 9 90) developed a model for experience-ba sed learning that focussed on helping students and staff to
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attend t o salient features of t h e lear ner. to understand
perspectives
regarding
their
pain
experience
and
provided by the settin g
hea lth beliefs, including the bases to those perspectives .
and learning activities . and to operate effectively i n
Such communicative management requ ires the practi
opportunities and con strai n ts
c h a l lenging a n d complex real-world learning environ
tioner's u nderstand i n g and skill in workin g with the
ments . The model emphasiz ed three stages o f engage
patient to reflect o n the patien t's perspectives and asso
men t
in a learning event: activities and experiences
ciated feelings.
prior to the event. d uring the event and and a fter the
Hagar ( 1 9 9 8 ) emphasized the connection between
event. Learners engage in noticing. intervening and
experience and reflec tion. He explored the various con
reflection-in -actio n . as we l l as rel1ection a fter the event
notations of reflection t hrough the works of different
that
(without the d i stractions of the setti n g ) , in order
authors. Dewey ( 1 9 6 6 ) . for example. req u ired
to make sense of and learn from their experiences.
education gives learners the li felong capacity to grow
Reflection a fter the event essentially involves feelings
and to readj ust themselves conti n u ally to their envir
and emotions. as well as intellectual work. Three elem
on men ts thro ugh ret1ective th inking, enquiry. democ
ents are return to experience. attending to feelings and
racy, problem solVing, active learning and experien tial
re-evaluation of experience (Fig.
learning. Dewey 's reflective thinking is ' ho listic. incorp
2 5 . 2 ) . The basic
pol i tical aspects of the
assumption u nder lying this model (Boud and Edwards.
orating socia l .
1 9 9 9 ) is that learning is always grounded in prior
con texts ' (Hagar. 1 9 9 8 , p. 3 7 ) . Schon's ( 1 9 8 3 . 1 9 8 7 )
moral an d
experience and that attempts to promote new learning
notion of the ret1ective practitioner emphasized the
must in some way take account of that experience.
practices of reflec tion in action : a spontaneous practice
S i nce learning builds o n existing perceptions and
of notiCi n g , seeing or feeling featu res of their learning
and Watki ns ( 1 9 9 0) l i nked
frameworks of u n derstand i n g . links must be made
and actions. Marsick
between new learning and what is known if lear ners
experience and reflection in their exploration of infor
are to make sense of what is h appen in g or has hap pened to them. This is par tic u l arly perti nent
for cl inical
as we l l as cogn itive and which situates learners (clinici ans a nd
of in t h e com
mal and i ncidenta l learning. Both of these are modes lear n i n g particul arly relevant t o lear n i n g
fiel dwork. which involves affective
plex i ty and bustle of cli nical practice. From the various
learn ing.
theories ex pl ored , Ha gar ( 1 9 9 8 . p.
patie n ts) in the social, psychologica l . cultural and
42) co nclu ded that
two major assu mptions u nderpinned effec tive work
materi a l environments o f profeSSional practice ( Boud
place/experience-based learning: ' that learning from
and Edwards, 1 9 9 9 ) . As discussed in Chapter 1. practi
experience
tioners often need to assist pa tients to reflect o n their
growth a n d development' a n d ' that i n a rapidly
i s fu ndamental to indivi d u a l person a l
Socio-c u l t u r a l context
MILIEU
Foc us o n : •
• •
Return to experience
learner milieu
Alle nd 10 feel ings
s k i l ls/strategies
Re·eval uate the experience
Prior to practice
Fig. 2 5 . 2
D u r i n g practice
Following practice
M o d e l fo r p romoting learning from experience. ( F rom Boud and Edwards,
1 999, based on Boud and Wa l ke r. 1 9 90.)
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E D U C AT I O NA L T H EO RY A N D P RI N C I PLES R E LAT E D TO LEARN I N G C LI N I CA L REASO N I N G
changing world successful and competitive enterprises req uire workers who h ave certa i n broad generic skills' .
• Assess m e n t and l e arn i ng Assessment faciJi tates. indeed shapes . learning, because students' respo nses to assessment govern what they learn . Stud ies by Marton and Salj o ( 1 9 76) and Ramsden ( 1 9 79 , 1 9 8 4 ) . for instance, have demon stra ted that assessment method s can profoundly inllu ence students ' approaches to learning, in particular their use of d eep and surface approaches to learning. Assessment is not, and should not be seen to be, an independent factor added on to learning prograrrunes to accredit learning. This perspective is increasin gly recognized in learning prograrrune design and imple men tation . A new 'holistic' view of assessment is needed (Boud and Higgs, 1 9 9 9 ) i n which (good) assess ment closely reflects desired learning outcomes and demonstrates a d irec tly beneficial in ll uence on the learning process. Assessment needs to be reframed as part of the total package of learning and assessment, focussing clearly on the assessment profile as students see it, in relation to the total learning experie nce. Students need greater opportunities to practise and gain feedback. and greater time for sel f- and peer assessment.
stron gly that effective learning involves interaction with others. Griffith ( 1 9 8 7) , for i n stance, d iscussed the concept of independence versus interdependence i n learning programmes. She s tressed the importance of learners valuing the contributions each can make to o thers ' learn ing. Sel f-direction in lea rn i n g i s widely aoknowledged a s a fundamenta l educational goal . HarriS ( 1 9 8 9 , p . 1 1 2 ) regarded the a i m o f self-directed lear n i n g as, ' to assist individ uals to take increasing con trol over their learning processes and content. In this way, they will d eve lop the realization tha t they have the power to alter their individual and social envi ronment and to create their own reality. This is the " empowerment v iew" o f adult education.' Self-directed learning embodies a number o f key e lements: autonomy, t h e pursuit of competence/ excellence, the variability and development i n a learner's capability as a self-directed learner over time, the vari ability between d i fferent learners' independent lear n ing abilities , the idea of learner responsibility for the learning process and outcome, and the notion that independent learning can occu r as an i n d ividual or group activity. In self-directed learn i n g programmes, the learner 's behaviour demonstra tes : • responsibil i ty for and critical awareness of his or
her learn i n g process and outcome high level of sel f-direction in performing learn i n g activities and solving problems that are associated with the le arning task • active input to decision making regard i n g the learning task • the use of the teacher a s a resource person • effective interaction with other lear ners and the te acher in a collabora tive learning mann er. •
What are the ro les of learn e rs? The learners' roles in higher education and professional development largely centre around self-directedness and lifelong learning. As pro fessio nals ( actual or prospective ) , they h ave the responsibility to p a rtici pate in ongoing learning and to use their learning and self-eva l u a tion skills to ma i n tain and enh a nce their capabilities .
• Self-d i rected l earn i n g
a
Practitioners, such as manual therapists, are ( ideally) constantly engaged in self-d irected lear n i n g as they critique their knowled ge, skills and abilities and seek to enhance them .
Wilcox ( 1 9 9 6 . p. 1 6 6 ) argued that 'self-directed learning's emphasis on personal autonomy, personal responsibility, and personal growth embodies some of the most fu ndamental principles of higher education ' . Self-d irected learning i s an approach to learning that is a derivative of adul t learn i n g and humanistic edu cation . It implies internal mo tivation for learning, rather than lear n i n g in isolation . Learners may elect to l ear n by th emselves ; however, many a uthors argue
• Life l o ng l earn i n g Li felong learning is a cen tral concept in the theory and practice of self-directed learning. For exa mple, Knowles ( 1 9 70) identified the main characteristics of self-directed learners as an increasing self-directedness. a rea d i ness to learn in relation to liIe tasks and roles , a rich background of experience that serves as a resou rce for learning. and an orien tation to learning
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that is problem-cen tred rather t h a n s u bj ect-ce ntred.
integrate le arni n g with work a n d actively encourage
A p r i nc ip a l goa l of i n h el p i n g students to bec om e sel f
empl oyees to lear n from the p rob l e m s , challenges and
d i rected lea r n e r s is to pro mo te the transfer of se l f
s u ccesses in herent i n eve r yd a y activities . 'By work i n g
d i rected lea r n i n g i n to l i fe a n d work situ atio n s . Such
in this c l i m a te of priority fo r l e a r n i n g . ind iv i d u als wi l l
transfer c a n be fac i l i t a ted, fo r i n s tance. thro u g h the
become more aware o f t h e need t o lear n . a n d w i ll be
a n a lysis of t he real p a t ie n t c a ses , as pr es e n te d in t h i s
hel p ed a nd encouraged i n the process of' l e a r nin g
boo k .
how to lear n ' ( G ibbs, 2 0 0 0 , p.
2 3 4 ) . Billett ( 2 0 0 1 )
B a teson ( 1 9 8 7 ; c i ted i n Rawson . 2 0 0 0 ) argued
c a u tio ned th a t , w h i l e l i felong lea r n i n g i n the work
t h a t lea r n i n g to learn is a level of l e ar n i n g ra the r
place is more i mpor t a n t than eve r. i n d i v idu a l s . how
t h a n p u re ly a skill set. B a teson proposed th ree levels
ever we l l motivated to pu rsue their professional
o f learning to learn .
d eve lopmen t. may be restricted i n this go a l i f the
Learning 1.
T h i s i nvolves c h a n ge in the specifi c i ty
of responses. At t h i s stage, lear ners le a r n to ar r i ve at a cor rect c h oice of prob lem or issue sol u t i o n . They a re n o t focus s i n g o n conc ep t u a l i zati on of the problem or i s s u e . Lea rn ing l l .
H e re , c h a n ge i n the process of learn
ing I occ u r s . A t this stage, l e a r ners are l e arn ing abo u t l e a r n i n g , n o t j u s t abo u t learning to solve problems. A h i g h e r leve l of critical t h i n k i n g and problem concep tualization i s i nvolved . The fi n a l stage i nvo lves change in the process of l earn i n g II. Here learners become con scious of their conceptions of the world , how they are fo rme d and how they a re c h a n ged . Lea r n ers become i n vo l ved in self-reflexive lear n i n g processes
Le a rn ing Ill.
( th a t is, l e a r n i n g that i s rel1ective a b o u t self as learner and perso n ) .
wo r kp lace constra i n s rather tha n s u pports l ea r n i n g o p p o r tu n i t i e s .
Ba ttersby ( 1 9 9 9 ) argued that ongo i ng learning i n t h e workplace
( o r conti n ui n g p rofessio n a l d eve l o p
m e n t) , can be enha nced by adopti ng the humanistic and tr a n s rormative imperatives associ a ted with learn i n g orga n izatio n s .
Ward and McCormack ( 2 0 00)
p l a ced a dult lear n i ng at the ce n t r e of practice develop men t as a means of creati ng a le ar n in g c u l ture to re s po n d to the desired lea r n i n g and organizational o u tcomes. Rawson ( 2 00 0 ) concluded that a l ear ni n g society requires a society of sel r-determi n i n g learners. not j ust
a
society of self-ma n a ged lea r ners: that is,
in dividuals who have the abil i ty to cha l l e n ge the s ta tus q u o a long with the skills to make the i r voices heard within the context of a d ia le ctic a l process between
d evelop i n g i n d ivid u als a nd developing societies .
Beyond t h i s level of lea r n i n g , it is argued , l ies a n o ther level i n w h ich not o nly does the p h i losophical perspec tive o f the lear n e r becomes a conscious act a nd a
developmen t goa l but also the capa city to create as well as ac q u ire new knowledge i s p ree mi ne n t . [n the earl ier section on p r a ctice epistemo logy, this leve l of
learning was in trod uced as a conscious, lear n i n g-as knowledge-generation process. in formed by c r i tical a nd reflexive i ncorporation o f the lear n e r s ' epistemo logical pe r s p ec t ive and goa ls into practice. This po i n t is a lso releva n t to some c u r rent views of evidence-based practice, which l imi t accep table evidence to propos itio n a l k now ledge a cq u i red thro u g h quan ti tative research (Higgs et a I . , 2 0 0 1 ; Jones and Higgs , 2 000 ) . S uch a restriction would limit t h e discovery o f new ide a s , a s the cutting edge of practice is frequently i n a d v a n ce of empirica l research a n d evidence. A n u mber of a u thors h ave consid ered the value o f the lear n ing e nv iro n me n t i n promoting a n d fac i l i tat
What so rt of work envi ronment w i l l grad u ates enter an d i nfl u e nce? For students. educators and g r a d u ate s of professional e n try educationa l prog rammes , the n a t u re o f the work enviro n me n t is an i mpo r t an t issue i n shaping c urr ic u l a and professio n a l deve l o p m e n t go als and s trategies. Te ac hers a n d le a r n ers, therefore. need to be fami l i a r with trends in health c are, with the na ture and expectations of professio n a l practice. and with the oppo r t u nities p rov i ded by wo rk-based le ar n i ng .
• Trends
in
health care
Health professio n a ls need to un derstand the continu ally changing world of work and prepare themselves for its demands. Changes in the h ea l th-c are ar e na includ e :
ing l i felo n g lear n i n g. Senge ( 1 9 9 0 ) , for instance. advo
• t h e c h a n g i n g v ie w of h e a l t h ( a s we l l n ess a nd as
ca ted the developme n t of l e a rn in g orga nizations that
commod i ty. r a th er t h a n as abse n c e of i l l ness)
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25 E D U CAT I O N A L T H E O RY A N D P R I N C I P L E S R E LAT E D TO LEAR N I N G C L I N I CA L REASO N I N G
• a re-evaluation o f the concept o f health care ( w i th
analysis also includes consideration of the broader
i ncreasing emphasis on hea l t h promotion a n d
e ffectiveness and efficiency of the patient's health-care m anagement, particular ly w i th respect to appropriate
comm u n i ty and m a naged care) • c h a n ges i n method s o f measu r i n g health (reflect
collaboration across the health professions.
ing broader issues o f l i festyle and society, e . g. socioeconomic status, rat her than measu res of i l l health) • l o c a l hea l th-care developments ( li nked to eco
nomic rationalism and m a n aged care)
• P rofessional
p ractice
Schon ( 1 9 8 7 ) c a l led the Held of professional practice
a
' swampy ' a re a . bec ause m a ny of the decisions made i n
• global hea l t h man agement deve l op m e n ts (in p a r
managing practice problems a re based on d ata and
ticular, c h a n g i n g patter ns of employment a nd
knowledge that a re o ften u ncertain, ambiguous o r
health-care ma nagement associated w i th global
h i d d e n . S i tuations to whic h professionals apply their
ized economies ) .
practice knowledge a n d skills are often complex beca use they i nvo l ve peopl e. Peop le bring to the situ
These changes h ave been accompan ied b y a growin g
ation their own perceptions, needs a n d experience.
d issatisfaction w i t h t h e med ic a l model as a complete
T hese features i n flue nce the nature of the he a l t h
o r releva nt strategy for emergent heal th-care needs.
problem. Problem c l a ri fication a nd m a n agemen t deci
One response is the adoption o f managerial modes o f
sions. then, cannot be made without reference to the
hea l t h care, w h U e a cou nterresponse seeks t o repos
person concerned. The nature o f professional practice
ition peop l e . not managment, a t t he cen tre of o u r
requires health professionals to develop k nowledge
health-care syste m . Hancock ( 1 9 8 5 . p. 1 ) a r g u e d t h a t
fro m their practice abou t the variety of contexts i n
' the emphasis h a s s hi fted from a simplistic. red uction
which t hey practise a n d t o develop advanced skills i n
ist cause-and-effect view o f the medical model to a
clinical reaso n i n g .
com p l ex , h o l istic, interactive h ierarch ical systems v iew k n own as an ecological model ' . This model focussed on the i n teractivity amon g people, h u m a n
• Wo rk- based
l earn i n g
society a nd t h e environment and on the intersection
'There h a s been a dramatic s h i ft i n rece n t years away
between e nvironment a nd culture, i n tegrati n g the
fro m v i e w i n g education a l institutions a s the pri ncipal
natural and social sciences (Hancock, 1 9 8 5 ) . Health
p laces i n which learn i n g occurs toward s a recogn i
care does not a nd cannot operate i n isolation from the
tion o f the power and i mporta nce o f the workplace
many l ocal and glo b a l forces impacting on people's
as
l i ves and environments .
a nd this has given rise to changing demands for learn
The medical model of health care is often appl ied in
a
site of lear n i n g . T he nature of wor k is c h a n g i n g
ing' (Boud , 1 9 9 8 , p . 1 ) . These arguments are hig h ly
a reductionist systematic manner rather than a holistic
applicable to u ndergraduate education in the health
systemic man ner. Adopting a social ecological perspec
sciences, where c l i n ical education (in the field) forms
tive i n the managemen t of hea lth care creates a more
a maj or avenue for s t udents to learn in the work
hol istic approach, which places people at the centre of
place setting about the expectation s of the work p l ace
the system and ensu res that the relationsh..ip between
and i ts stakeholders a n d the development of a profes
h ealth care and costs focusses on the health care of
sional iden ti ty.
people not on the operation and sel f-perpetu ation of
through their work is a vital element o f professi o n a l
the health-care system. At a more individual level.
development .
For
g r a d u a tes,
learn i n g
in
and
clinicians, whether conSideri n g the cases in this book
N e w trends i n v iewi n g and u s i n g workplace learn
o r reasoning in their own practice environments, need
i n g i l l u s trate a col lapse in the d i fferences between
to go beyond trad itional diagnostic reasoning and more
practice and theory, between body and m i n d , and
overtly develop their prac tice knowledge and skiUs in
between lear n i n g and work (Boud , 1 9 9 8 ) . Learning in
non-d iagnostic reasoning. Manual therapists of today
the workplace i s in creasingly gai n i n g
must be able to conduct n arrative and collaborative
own, replacing the old view of the workplace as some
�eason i n g and practise communicative (not just instru
where to practise the knowledge and skills learned in
mental) management (Le. t hey need to develop skills
academia . The value of the workplace as a key site for
of psychosocial assessment and management) . This
learnin g is evident when we consider the n ature of
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a
value o f i ts
T H E O RY A N D D EV E L O P M E N T
t h i s workp lace and t h e learn i n g opportu n i ties i t pro
presen t learn i n g a s deep, d iscovery, problem-based,
vides. In partic u l ar, learni n g in the workplace i s con
autonomou s ,
textu alized and consequentiaL rather than isol ated
Gohnson, 2 00 0 ) . In dealing with a real wo rkpl ace
from the reality o r impact of practiSing s im i l a r profes
problem, Johnson ( 2 0 00) argued that learners respon
experien tial.
action
and
work-based
sio n a l s k i l l s or developing professi o n a l k nowledge i n
sible for solVing the problem will become part of their
the classroom. T h e c o n text o f t h e workp lace changes
own research (Watson , 1 9 9 4 ) , adopting an action
rapidly, both loca l l y and i n response to the d y n a m ics
lear n i n g approach. 'Action learning seeks to prov ide
of exter n a l forces ( e . g . gover n m e n t pol icy a nd eco
both a formalized learning opportu n i ty and a means of
nomic changes) . Cl ien ts bring their own complex and
developing the individual's learning a b ilities' Gohnson,
unique situations, c u l tures, needs a nd ex pecta tions to
2 000, p. 1 3 1 ) .
the professiona l-client interaction. Fur ther, the work p lace en gages d irectly with employer, gover nment and c l i e n t expec tations of quality standard s of service delivery and i n terpersonal i n teractio n . Each o f these factors m akes the work place (particularly for health care professio n a l s engaged directly w i th the q u a l ity of people 's l ives) a n essential and invaluable fo rum for learn i n g and profess ion al developmen t. Also of impor tance has been a c h ange in the way people need to lear n and a sharpe n i n g of the concept of l ifelong learni n g , which should i mply continuous learn ing that i s responsive to con tin u al environmental changes, not j ust learning throu ghout the duration of a working li fe . In work-based learning, lear n i n g i s a s tudent-cen tred continuous process grounded in expe rience (Sangster et a I . , 2 0 00 ) . Work-based learning adopts 'a structured and learner-managed approach to maximizin g opportu n ities for learning a nd profes sional development
in the workplace' (Flana gan et al . ,
2 00 0 , p . 3 6 0 ) . C h aracteristics o f work-based learning ( b ased on Fos ter, 1 9 9 6 (as ci ted in Flanagan et a I . , 2 0 0 0 ) ; S a n gster and Mars h a l l . 2 00 0 ) are :
H ow can learne rs b e p repared fo r the real ity of the workplace? To fa ce the real world 0 [" work and to con tinue to m a i n t a i n a nd en hance competence i n the face of the know l edge exp l o s i o n , advanc i n g technol ogy and the c h a n g i n g work contexts in the hea lth and social ser v ices aren a s . s tudents must be effective and comm i t ted l i felong lea r n e r s . Profess i o n a l social ization is the framework for deve l o p i n g these skills a nd co mmi t men t , a l o n g with a confident yet evol v i n g profes sional iden tity a nd broader tec h n ical a n d generic competencies . Two valuable strategies fo r fac i l itating the p r o fessio n a l soci a l ization process are fiel dwork education and peer lea r n i n g . Fieldwork (or clin ical) education provid e s the re a l -wo r ld context that most closely reflects the complex ities and contingencies of the vario us socia l service contexts wh ere hea l th profe s s i o n al s wor k .
• s t u d e n t cen tred
• C l i n ical lfi e l dwo rk edu cation
• a u tonomously managed
The ed ucation o f h e a l t h professi o n a l s is d istinguished
• team-based and cooperative, relying on partnerships
by their exposure to real-life practice through fieldwork
• i n terd i sc i p l i n a ry
education. Whereas clinical education trad i tionally
• concerned wi th performance en h a ncement and
involved the supervised practice of profess ional skills,
upgrading experience
fieldwork and clinical education today are becoming
• p rocess oriented , activity based and performance rel a ted
more common ly recognized as opportunities for learn ing and professional social ization , not j ust for practice.
• problem b a sed ; foc u s s i n g on complex work- based problems
Apar t from develo p i n g their professional identity and preparin g for t he complex ities of real-world practice
• c a p a b l e of prod u c i n g new theoretica l i n s i ghts
in
clinical settings , students and graduates particul arly
• e n c o m p a s s i n g both educ ation and tra i n i n g
need to employ these settings to develop their clin ical
• lifel o n g l e a r n i n g
reason ing skills and management ski l l s . The goals of
• innova tive, foc u s s i n g o n new approaches t o ga i n
clinic a l education (Higgs et a l . . 1 9 9 1 ) inc l ude:
experience a n d m a n age c h a n g e .
• contributin g to the development of the student's
The value o f work-based learning i s supported b y a
understand i n g or he a lth, il l n ess
range of lear n i n g theories , including theories that
system
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and the health-care
25
• • • •
• • • • • • • • • •
E D U CATIONAL TH E O RY A N D PRI N C I PLES R E LATE D TO LEA R N I N G CLI N ICAL REASO N I N G
awareness o f o w n attitu des . values and responses to health and i l l ness ability to co pe e ffectively with the demands of the professional rol e u n derstanding of the i nter-related roles in the hea lth-care team clinical competencies relevant to the studen t's discipline. inc l u d in g c l i n ic a l reaso ning skills , psychomotor competencies. interpersonal a n d communication skill s ability to provide a sou n d rationale for i n terven tion/ actions skills i n the education of relevant people. e.g. patients. c l ients. the commu n i ty, staff self-manageme n t skills. e.g. time a n d workload m a n agement ab i l i ty to process, record and use data effec tively abil ity to eva l u a te critica l ly and develop one's own performance a b i l i ty to review and i nvestigate the quality of c l i n ical practice professi onal accou ntabi l ity. commitment to cl ien ts/sel f/employers commitment to mainta i n i n g and developing pro fession al com pe tence s k i l l s necessary lar li felong profession a l learning ability to respond to changing commu n ity health care needs.
Clinica l education can be considered as a mode of work-based learnin g , defined as ' student learning for credit designed to occur either i n the workplace or in on-campus settings that emu late key as pects of the workp lace' (Reed ers, 2 0 0 0 . p. 2 0 5 ) .
• Peer learn i n g Learning w i t h peers is a usefu l strategy for t h e devel opmen t o f complex cognitive skills such as clin ical reason ing. Worki n g with peers on collaborative deci s ion maki ng and receiving feedback from peers helps practitioners to d evelop their reasoning in many ways: they become more aware of how they reason, t hey learn to be more critic a l of their reason ing, t h ey learn reasonin g alternatives throu gh listening to others' reasoning, t hey recognize the limits of their reason i n g ability/knowledge by receivi n g feedback fro m others, and they gain competence i n articulation o f the ir reaso n i n g . T h r o u g h reason i n g aloud with peers and critiq uing their rea soning, practitioners can gain
valu able i nSights i n to the (l argely) u nobservable process of d ecision maki n g . For a successful peer learning experience to take place. i n terd epe n dence, i n divid u a l accou n tability and grou p-processi n g abil i ty need to be presen t (Johnson . 1 9 8 1 ) . Peer lear n i n g c a n i nvo lve n ovice practiti oners learn ing a longside their peers. This can enh a nc e professional com petence and reason i n g skills ( Ladyshewsky et a ! . . 2 00 0 ) . foster peer d i scussion i n the work p l ace set ting to promote exposure o f the learner's thoughts and arguments, and a l low d iscussion and restructuri n g of knowledge ( Regehr and Norman. 1 9 9 6 ) .
S u m mary
• W h i c h l earn i n g theory to fo l l ow How do we, as teachers and learners, know which learning theories to choose? F igure 2 5 . 3 illustrates the factors to consider in the ranges of choices we can mal<e in seeking to pla n and i mpleme n t relevan t learn ing prog rammes. The educational strategy of c hoice depends on thoughtful application of available theory and knowledge/evidence to the given situation ( includ i n g n eeds , preferences, etc.) . First . teachers (and learn ers designing t heir own learning programmes) need to be familiar with theories and contexts of lear ning. Secondly, a number o f factors must be considered . such as consumer/participant differences (e.g. needs and goals) , vari ables specific to the situ a tion (e.g. the pro fes sional context and topic to be learned), and bro ader context or ' big picture' issues (e.g. community expec tations and trends in education) . Teachers and learners bring to the learning process a n umber of skill s and capabilities. including their skill in using different l e arning styles/approaches. reflexivity, creativ i ty and the capacity to explain and understand concepts and phenome n a . In drawing these factors together, a number of teaching and learn in g princi ples can be employed, such as identification of salient factors. the pursuit of authenticity in matching espoused and prac tised principles and strategies, and the creation of learning environments that promote mutual respect amon g learners and teachers. Readers are invited to reflect on the para llels between educational decision mal<ing presented i n Figure 2 5 . 3 and clinical decision making using coll aborative decision making wi thin a broad evidence-based and patient! client-centred framework.
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'ta T H E O RY A N D D E V E L O P M E N T U s e o f a v a i l a b l e knowledge/evidence:
S k i l l s a n d c a pa b i l ities u sed : Teachers' a n d l e a rn e r s ' :
T h e o re t i c a l k n o w l e d g e
vISion reaso n i n g decision m a k i n g creativity l e a rn i n g ( i n various styles) ref l e x i v i ty m e t acog n ition eva l u a t i n g
Research-based k n o w l e d g e E x p e rience- based k n o w l e d g e
Factors to consider: P a rticipa n t/co n s u m e r differences: • goals • needs • c h a racte ristics • capabilities
Outcome:
P r i n c i ples u sed :
P rogra m m e s u i ted to p a rt i c u l a r l e a rners' needs i n t h e i r
Broad context: • c u l t u re • system g o a l s • e x p e c t a t i o n s of s t a k e h o l d e rs • t re n d s in education • external constraints, oppo rt u n i t i e s , i n f l u ences • n a t u re of workplace
25.3
i d e n t i f i c a t i o n of s a l i e n t factors , n e eds, i n fl u ences tailoring learn i n g to t h e particu l a r n eeds of the l e a r n e r a n d s i t u a t i o n
•
con g ruence
p u rs u i t of m e a n i ngful m a t C h i n g among programme d i m e n s i o n s
•
a u t h e n t i c i ty
g e n u i n e , co h e re n t m a tc h i n g of espoused a n d practised p r i n C i p l e s a n d s t rategies
•
recog n i t i o n
acknowled g e m e n t a n d u t i l ization o f preferences a n d capabi l i t i es of teach ers and learners
•
affirmation
•
c o l l a bo r a t i o n
of d i fferences of c u l t u re etc. working t o g e t h e r on g o a l s , processes a n d eva l u a t i o n of l e a rn i n g
•
responsiveness: vision
to o p p o rt u n i ti e s , l i m i ta t i o n s , supports consideration of l o c a l and l a rger d e m a n d s , c u r re n t a n d f u t u re needs
•
mutuality
of respect a n d empowerment
Factors i nfluencing plan n i ng a n d implementation o f learning programmes .
theory (conceptu a l izations and visions of practice) and
F i g u re 2 5 . 4 i l l u s trates on e way o f p u tti n g these m a ny ideas toge ther, It places learn ing a t t h e core w ith a roe u s on the ro ur core l e a r n i n g capabi l i ti e s or ap proaches proposed by Ko l b ( 1 9 8 4 ) . I n fo r m i n g deci s i o n m a k i n g a b o u t te a c h i n g are lea r n i n g t heories , the teacher ' s and learner's experie nce, a commitme n t to l e a r n i n g w i t h others, b e i n g enriched by their experi ence and aspirations, and the par ticu lar aspects o f the l e a rn i ng task a n d situation. T h e s e factors o c c u r a
salie nce pa rt i c u l a ri ty
•
• P u tting it a l l toget h e r
w ith i n
•
•
context
Situation specifics: • context/location • sett i n g c h a racteristics • resou rces • t o p i c area • p rofessi o n a l i d e n t i ty • l e a r n i n g progra m m e
F i g.
meaning making exp l a i n i n g self-appra i s a l cu l t u rat competence team work leaders h i p planning changing
m u l t i faceted c o n text w h e r e r e a l i t i e s , expect
a ti o n s and visions i n teract to produce rich and com plex e nvironments for l e a r n i n g .
from experience ( re(1ection on practice, giv ing rise
to
p rofessional craft know ledge ) . At the core of aU the forms of kn owledge un d �rpinnin g practice lies practice epistemo logy, That is, u nd ersta ncling how knowledge is generated , knowi n g i ts sources , understanding the need for rigou r a n d o n going cri tical rellection in the constant appraisal and evolution of practice know ledge, and recognizing the situated ness a nd
salience of
th is kn owledge allows the knowledge user ( teacher, pract i t i o n er, l e a r ner) to use k n owled ge w i s e ly. Herein lies the essence o f practice wisdom, which provides t he fo u n d ati o n for profeSSion a l a r tistry i n p ractice. We need ,
in
our lea r n in g and tea c h i ng (of cl inical
reason i n g ) , to recogn i z e that prin Ciples and theories
• Teac h i n g as a r t , c raft and
science
o ( lear n ing. and other educational tools such as ' evid ence-based te aching practice ' . are simply
guide
Teaching is a b l e nd of a r t , craft and science. T h e educa
lines that the teacher and learner can use to facilitate
tion a l cliscourse, principles a n d theories releva nt to
learning. The optimal lear n i n g slTategy for a given situ
clinical reasoning have been described , emphasizing
ation depends on m a ny factors as discussed above.
in learning (e.g. varying learning
the p araJ lel s between reasoning and lea r n i n g i n the
Advanced skill s
imprecise worlds of teachin g , learning and profes
styles. self-directed lear n i n g ) a nd teaching need to be
sion a l practice. These prinCiples and theories have
developed. Advanced skills in teac hing can in clude
arisen from research ( the science of teach i ng ) , from
metacogni tive teaching ( i . e , chOOSing an educational
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2 5 EDUCAT I O NAL T H E O RY A N D P R I N C I PLES R E LATE D TO LEA R N I N G C L I N ICAL R EAS O N I N G
",
/
/ I
I
/
-
-
-
-
-
- .....
CONTEXT
"
/
"
,
Complex competencies
Professional a utonomy
�
especially change agency
and res pon sibil ities
\
Professional soc i a l i zation
\
\
\
I
1
I
I
\
\
\
Workplace context -
Self-d i rected, l ifelong lea r n i n g
\
,
changes and rea lities
P ractice
,
"
"
" ..... -
Fig.
25.4
-
-
-
-
I
/
Change
epistemology
/
I
/
/
",
S u m m a ry.
and philoso phica l stance, u t i l izing
a
base of t h e subject area : Higgs . 2 0 0 1 )
rich kn owledge
and
the cre a ti o n
s u fficient a n d appro priate structure to ma tch the
l earner's readi ness for the task: Higgs, 1 9 9 3 ) . This is
of l i b e r ati n g learning frameworks ( i . e . learning s i tu
expanded in C h a pter 2 6 ,
ati on s characterized by contr o ll ed freedom that provi de s
enhancing clin ical reaso n i n g .
which d e a l s with ways of
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practice: rac U i tatln g work-based
Journ a l o r A l l ied Hea l t h . 1 3 . 2 7 2-2 7 9 .
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M a nagem e n t. 5 1 . 5 7 7- 5 8 7 . Wi lcox. S . ( 1 9 9 6 ) . Foste r i n g selr-d i rected l ea r n i n g i n the u n iversity setting. S t u d ies i n H i g her Ed u c ation . 2 1 . J 65-176.
I m provi ng c l i n i cal reaso n i ng i n m an u al t h e rapy
Darren A. Rivett and Mark A. Jones
Clinica l ex pe r ti se i n ma n u a l thera py i s d epen d e n t on the
t h e reaso n i n g a b ility to recognize the cl i nical va l ue and
deve l opmen t o f
re leva nce of i n formatio n . a n d the c a p a c i ty to access it
a
h i gh l evel of s k i l l in m a ny aspects of
p r ofession a l practice. S u perior tech n ic a I s kill s , advanced commu n i c a t i o n s k i l l s ct nd a su bsta n ti a l s tore o f know
technic a l s k i l l s m u s t be a s s oc i a ted w i t h ' i i/the n ' r u les of a c t io n ;
l edge
otherw ise their a p p l i c a t i o n may b e i n a p p r o p r i a t e and
a re
fea t u res commonly rega r ded as core compon
e fll c i e n tly i n the c l i n ic a l c o n tex t . S i m il a rly.
ents of c l i n ic a l ex per t i se . However. t.hese compo ne nts
their value u nrecognized . Therefore, good skills i n clini
0 1' c l i n ical pe r fo rma nce are a l so often iden tillable in the
c a l rea so ni ng are needed to make the most of new pro
' average' ma n u al t he r a pis t ,
ced u r a l i n fo r m a t i o n and avo i d ' i n fo r m a tion overload'
their
who, while c o mpe te n t i n
l1 eld , i s n o t recog n ized as a le a d i ng practitio ner.
The miss in g
Irom t h e ever i ncreasing a mo u n t o f profession al know
factor. which d iffe re n tia tes the expert from
ledge. W i t h o u t them. the cl i n i c i a n i s at risk of u nq u es
ot her c l i n icians. c o u l d we l l be cogni tive or c l i n i ca l
ti on in gly accepti n g ' fash i o n a b l e ' practices a n d m a n u a l
reason i n g s k i l l-a pe r forma n ce compo n e n t that is
therapy becomes merely
not as rea d ily apparent to c a s u a l observe r s . A l t ho u g h
sou n d tech n i ca l
a
tec h n i ca l operatio n .
As d iscussed i n C h a pter 2 5 , i n tera cting profeS S i o n
a n d commun ication s k i l l s ( and asso
a l s c a n be characte rized b y ski l l s i n proble m so l v i n g ,
ciated knowledge) a re needed to elicit o p t i m a l cl i n i c a l
cl i n i c a l reaso n i n g , reflec tive p r a c t i ce and critical s e lJ
is only as use fu l a s the
e v a l u a t i o n . i n a d d ition to self- d i rected l e a r n ing (see
c l i n i c i an's rea son in g s k ilJ all ows . That is, i t is t he thi nk
Tab l e 2 5 . 2 ) . T he ro l e o f the hea l th p r o fe s s i o n a l a s a
d ata , t h e i n fo r m a t i o n obtai ned
ing o r reaso n i ng processes that g u id e the col l e c t i o n o f
learner was s i m i l a r ly i d e n t ified as compri s i ng self
clin ica l d a ta a nd extract the va l u e of
the d a ta fo r m a k
d irec t io n , l i fel o n g le a r n i n g a nd the generation of new
Whi lst mos t m a n u a l t h era p i sts a re d i l i gen t i n
u a l thera p i s t , b o t h a s a n a u tonomous h e a l th profes
u n dertak i n g continuing e d u c a tion t o deve l o p n e w
s io n a l a nd as an ad u lt l e a r ner. takes r esp o n s i b i l i ty fo r
m a n u a l sk i l ls a n d acquire k nowledge perta i n i n g to
i mprov i n g t h e i r c l i n ical reasoni n g ability. S i mila rly.
ing c l i n i c a l de c is i o n s .
k nowl edge . Accord i n gly. i t is impo r t a n t t h a t t h e m a n
is a respon s ibi l i ty for teachers of ID a n u aJ
c l i n ic a l t heory a n d research . t h e re is a ten d ency to
there
n egl ect t h e development of cli n i c a l reaso n i n g sk i l ls . New ly a c q u ired facts a n d tec h n iq ues are o ften ini t i a l ly e m p l oyed w i t h en t h u s i a sm but soon fa l l by the way
to te a c h skills in c l i n ic a l reaso n i n g . There a re m a ny
s i d e a s res u l ts fa ll short of expec tation ( Rivet t , 1 9 9 9 ) .
These i nc l u d e exte r n a l factor s , such as the i nc reas i n g
This is common ly
dema nds o f fu ndi n g agencies a n d p a t i e n ts t o b r i n g
bec a u se short continuing education cou rses in m a n u a l therapy often fa i l to a d d ress the necessary associated c l inical rea so n i n g ski l ls. The i n te gration of new i n fo r m a t i o n with ex i s ti n g ca te g ories of c l i n i ca l k nowle d ge wi l l ge n era l ly be lim ite d without
therapy
factors that s h ou l d m o ti v a te c l i n i c i a n s or l e a r ners to s trive for g reater expertise i n their
thinJdn g s ki l l s .
about a qu i ck and effective reso l u tion to t h e p a tien t ' s p r ob lem, and i n ternal factors , s u c h as
work sa tisfaction
and the res pect of peers . A l t h o u g h these a re strong motivational factor s , frequen tly c li nicians are u naware
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403
1[."
T H E O RY A N D D EV E L O P M E N T
of t h e importance of reasoning skill s i n developing clin
criter i a . Clinical ex pertise, of w h i c h clinica l reasoning
ical expertise or do not know how to go about improv
i s a critical component. can be viewed as a continuum
ing their cog n itive skills. It i s the aim of this chapter to
along multiple dimensions (Higgs and Jones , 2 0 0 0 ) ,
address both these issues.
inclu d ing clinical outcomes, person a l attributes such a s pro fess ional j udgment a n d empathy, tec h n i c a l clin ical ski l l s , commu n ication and i n terpersonal sldlls
The expe rt c l i n i ci an
( needed to i nvolve the patient and others in decision making and to consider the patien t's perspect ives) ,
Clinical expertise is of i n terest to aU co ncerned in man
s o u n d kn owledge base, and cog n i tive and metacogni
ual therapy : c l inicians want to be able to solve problems
tive proficiency ( i . e . clinical reason i ng skill s ) . T here
encou ntered in c l i n i c a l practice: patie n ts wa nt to be
fore, a d d itio n a l characteristics of ma n u a l therapy
treated by manual therapists wbo are highly competent
exper ts (Higgs and Jones, 2 0 0 0 ) wou ld include:
Oensen e t ai., 1 9 9 9 ) : and funding a gencies w is h to e n s u re that patient management is both effi c i e n t and
• recog n i z i n g the value o f d i ffe rent forms of know l edge in the i r reaso n i n g and u s i n g t h i s k n owledge
e ffective. Tra d i t i o n a l ly. c o l leagues and p a t i e n ts h ave revered practitioners who h ad accu mulated many years of experien ce at the c l i ni c a l ' coa l face ' , commonly g ra n ti n g them ' exper t ' status. However. there is now a consensus amongst researchers studying ex pertise in professio n a l practice that c l i n ic a l experience, although essentia l , is o n ly one component, a nd, in fact, ma ny experienced clin icians never truly become experts . This begs the question as to ' wh a t defi nes c l i n i c a l exp e r tise
critically • s h a r i n g t h e i r expe r t i s e to help to c u l tiv ate exper tise in others • communicating the i r reaso n i n g w e l [ a n d i n a man ner appropriate for the audience • demonstrating c u l tural competence in t heir rea soning and communication • employing
and how c a n i t be a tt a i ned ? '
have identified c h aracteristics o f expertise that appear
to
generate
new
limited • possessi n g a patien t-centred v iew, u n d er s ta n d i n g a n d respond ing appropriately t o pa tients ' exper i
to be generic ( G l aser and C h i , 1 9 8 8 ) . Expe r ts : • excel m a i n ly i n their own d o m ai n
th ink i n g
poor. and ad apt treatment when resou rces are
Research in to expert behaviour in a nwnber o f fields ( e . g . physics , mathem atics . medicine, chess p l ay i n g )
lateral
hypotheses, redesign treatment when prog ress is
ences , perspectives and expectati o n s • valuing
the
p a r ticipation
of
relevant
others
• perce i ve l arge meaningfu l pa tter n s in t h e i r dom a i n
( p atie n t s , caregivers , members of the hea l th-care
• are fa ster th a n n ovices at performing t h e ski l l s o f
team) in the decision-making process.
their domain , a n d solve problems wi t h greater acc ur a cy a n d less effo r t • h ave s u perior short-term and l o n g-term memory • see and represe nt a problem in their d o m a i n a t a deeper and more principled level t h a n novices ( i . e . novices tend t o represe n t a problem a t a s u perficial level) • spend a g reat deal of time a n alysing a problem qu a l i tatively • h ave strong sel f-monitorin g ski l l s and employ h i g h levels of metacognition i n their c l i n ic a l reasoning • possess the affective dispositions (e.g. inquisitive ness, self-c o n fi dence, open-mindedness , flex ibility. honesty, d i l igence, reasonab leness, empathy a n d hum ility ) necessary to refle ct o n a nd learn fro m their experiences .
The last two c h aracteristics merit closer ex amination. Whi l s t ex perts are expected to demonstrate superior clinic a l performance, this i s often o n ly viewed with respect to diagnostic accuracy and treatment outcomes (Higgs and Jones, 2 0 0 0 ) . However. the d escription of c l i n i c a l expertise requ i res a broader pers pective that incl udes the patient's u n ique experi ence a nd percep tion o f their problem . T h a t is. it is inadeq u ate s i mply to j ud ge c l i n i c a l perfo r m ance and the associ ated c l i n ical reaso n i ng on the basis of c l i n ical res u l ts. such as whet her the s urgery or the rapeutic i n terven tion worked. ReCip i e n ts of hea lth care may have rega ined their health or fu nction yet still fee l the c l i n i c ia n ' s per formance was i n adequ ate. S h a red decision making between patient and clin ician is important if 's uccess ' is to be real ized from the patien t's perspective. T herefore.
In addition to these generic skil l s , c l i n ica l expertise
c l i n i c al expertise requi res the clinician to be attuned
in the h e a l th professions needs to satisfy add i t i o n a l
to the patie n t ' s pain o r i l l ness experience.
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I M PROVI N G C LI N I CAL REASO N I N G I N
• E xpert reaso n i n g p rocesses It has been su ggested (Simon. 1 9 8 0) that it takes at l eas t 10 yea rs of experience to obtain pro ficiency in a ny proress i o n . W h i l e experience is o bviously necessary to o b t a i n expe r t s t a t u s . it i s equ a l ly recogn ized t h a t i n d i v i d u a ls with compara b le ye a r s o f experience can h ave marked ly d i ffere n t levels of exper tise. The development o f c l i n i c a l ex pc rtise. pa rtic u l a r ly exper tise i n reasoning. req u i res m u c h more than j ust ' c 1 o c k i n g u p ' years of c l i n ic a l exper i e n c e . It is impor tant to u ndersta nd the reason ing processes used by
cl i n
i c a l exper ts because t h i s facilitates critical
eva l u ation and enha ncemen t of our own clinical rea s o n i n g s k i lls. Research has determined that exper ts typically use in duct i ve or forward reason i n g ( i .e. pr ob lem cues elicit understand i n g and recognition of the solution strategies without any specific hypothesis test i n g) when dealing with a fa m i l ia r problem; this i s an e fficient process that e n ables them to solve problems qu ickly with l ittle error. This form of cl in ic a l reaso n i n g h a s low demand o n cog n i t ive capacity and thus frees up the rema i n i n g capacity for o ther tasks. However. when confronted with an u n fam iliar or complex prob lem. experts wi l l revert to the slower and more cog n i tively demanding ded uctive or b ackward reaso n i n g ( i . e . hypot h ese s e licit a retur n to the data for either re-in terpretation or collection of further confirming or negati ng evidence) (Elstein. 1 9 9 5 ) : t h i s is the process typically used by novices. In a d d i ti on. it should be noted . as discussed in Chapter 1 . t h a t j u d gme nts directed toward u nderstanding patients' pain experience from their perspective are reached thro ugh consensus valid ation between patient a nd th erap i st . as opposed to the more instr u mental process of hypothes is testi n g used to validate diagnostic j udgme n t s pertaining to pathology and phys ical impairment. Ex p ert i s e i s l a rgely domain specific a nd req u i res extensive exposure to a variety of clinical presentations and problems. The prompt retriev al of a weU-structured associ ation of d ata is necessary for inductive reasoning. This process of pattern recognition is dependent on the possession of. and the ability to use. a deep and highly o r ga n i z ed k nowledge base b u i l t mainly on a wealth of clinic a l experience ( E l ste i n . 1 9 9 5 ; Jensen et a l . . 1 9 9 9 ; Jon e s . 1 9 9 9 ) . T he process o f reco g nizi ng relevant cues and perceivi ng patterns amongst these cues requires accessing pertinent information from the databank of previous cases . Con sequ ently. pattern recogn ition is an extremely specific knowledge-based problem-solving
M A N UA L
T H E RAPY
' I
strategy ( i . e . i t is case speci fic) and constitutes a form of ' knowing-in-action' (Schon. 1 9 8 3 ) . It is. th e refo r e. apparent that a superior organ ization of knowledge (propositional and non-propositional) is a key featu re di fferentiating the expert from the novice cliniCian. and t his helps to explain why exper tise is d o m a i n specific and does not re a d i l y transfer across fields. A well-structured knowledge base enables effi cient and accurate clinical reasoning by facilitating ease of i n formation retrieval. A l s o , by h aving a greater abil ity to recognize relevant information and o r gan iz e it into meaningfu l c h u nks or patterns . exper ts save space in their wo r kin g memory for o ther cogn i tive processes ( e . g . metacogn ition) . However. ready access to th eir lmow ledge b a se requires t h a t experts acqu i re their kn owledge i n th e context i n which i t will be used . that i s i n the clinical con text. Indeed . l earning theory con tends that optimal learning occurs when knowledge is presented and l e arned in an authen tic contex t ( i .e. in se ttin gs an d a pp lica t io ns that would normally involve th at k nowledge) (Lave. 1 9 9 6) . This princi ple app l ie s to the development of clinical reaso n i n g skills both i n the u nd ergraduate student d u r i n g cl i n ic a l/ fiel dwork education and the experienced manual therapist in their own practice (see p. 3 9 6 ) . A n exper t ' s profession a l craft knowledge evolves as they continually learn from their clinical e xperie n ce s . ideally critiqued throu gh continual review of research validated evidence. This is principa Uy achieved through reflective enquiry during (re!1ection-in-action) and after (reflection-a bout-action ) the patient encounter (Jensen et al. . 1 9 9 9 ; Jones et al . . 2 00 0 ; Schon , 1 9 8 3 . 1 9 8 7 ) . Both ['orms o f reflection allow fo r self-cor rection a n d adaptation o f practice (including on - t h e- s p o t ex peri mentation with rel1ection-in-action) and help cl i nici an s to make sense of their combined research and experi enced-based knowledge to D n d . with the patient. an ef fe c t iv e appro a c h to the problem . For this. refl e c t i o n must include cri tical consideration of the reliability and valid i ty of information obtained, the p atter ns recog nized and their level of substantiation. and recognition o f the l i mitations i n t h e c li n ician's own knowledge and skil l s . In this way. reflective reason i ng also leads to conflfmation or refin ement of old pa tter ns and acquiSition o f new patterns. which may be h i d d en within the ambiguity of a clin ical presentation . Experts become experts . in p ar t. because they know t heir own limitations and this drives them continually to broaden and deep e n their u nder stand i ng o f people a nd t heir proble m s . Importan tly. for meaningfu l c h an ges i n
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T H E O RY A N D D EVELO P M E N T
knowledge structure to occu r. the learner must relate the new lea r n i n g experience ( academic, cl inical o r personal) t o their prior u nderstanding, whic h , i n turn, wil l lead to c h anges i n reaso n i n g . There is an obv i o u s a n al ogy between t h i s reasoning process and t h a t o f experiential learning (described in Ch . 2 5 ) as i nvolving reflection-in-action and reflection a fter the learn i n g event. A l though professional craft or proced ural know ledge is par ticu l arly highly d eveloped in expert clin icia ns (Higgs and Bithel l . 2 0 0 1 : Jense n et al . , 1 9 9 9 ) , it seems that biomed ica l knowledge is n o t explici tly u ti lized by expert practitioners when diagnosing a familiar problem . Boshuizen and Schmidt (2000) have proposed t h a t this i s beca use biomedical knowledge has been i n teg rated into, or subsumed u nder, the ex per t ' s c l i n ical k nowledge d u ring c l i nical ex posure. Bio med ical know ledge appears only to be explici tly accessed i f the ex pert is dealing with a diffic u l t o r u n f'ami l iar prob lem for which t h e i r d o m a i n know ledge i s i n a dequate. genera l ly as part of a backward-di rected causal reason i ng strategy within the hypothetic o-ded uctive process (Bos h u iz e n and Schmidt, 2 00 0 ) or when com m u n i c a t in g t h e i r reaso n i n g t o o thers ( Patel and Kaufm a n , 2000). T h e c l inica l patter ns or illness scripts used b y expert clinicians conta i n a n association o f c l i nica l ly relevant and easily retrieved i n form ation that aids accurate and rapid reason ing (Sefto n et a l . , 2 0 0 0 ) . Boshu izen and Schmidt (2 000) have identified three main components of illness scripts: en abl i n g conditions of the problem. e. g . hered i tary, soc i a l a nd other factors affecting hea l t h a nd the cou rse of the condition • the fa ult or pathophys iologica l process in an ' encaps u l ated ' form • consequences of the fau l t . that is the signs a nd symptoms of the d isord er. •
Illness scripts or clinical patterns a re m a tc hed to the information provided by the patient and generate expect ations abou t other signs and symptoms. thus g u i ding the enquiry process . There is a risk, however, that u n critical use of this cognitive process can h abitu a te the exper t's thinking to the detrime nt of n exible, open m i n ded and in nova tive thi nking. Accordi n gly, experts employ strong metacognitive skil l s to se l f-monitor a n d self-eva luate t h e i r thin k i n g processes. It is genera lly accepted that the abil i ty to be cognitive ly self-aware and sel f-critic a l is essential for ski lled c l i n ical reaso n i n g
(Brooldlel d . 1 9 8 9 : H iggs a n d Jones, 2 0 0 0 : Jensen et a l . . 1 9 9 9 ) . Witho u t metacogn ition . reason ing i s less responsive to the dynamics of problem-solving con texts and less capable of effectively dea l i n g with the comp lex ity of clin ical problems and t he d i versity of people a nd circu msta nces w ith i n which they occur. Because advanced clinical reaso n i ng requires metacog nitive as wel l as cog n i tive ski l ls . the manual therapist must lea rn to deve l o p the abi l ity to think on two level s simu l ta neously. S k i l led reflective metacog n i tive cl in ical reas o n i n g can . there l'ore. be seen to be a n a l ogo us to Bateso n ' s third level of learn i n g (Lea r n i n g III: self reflexive l e ar n i ng ) (Bateson. 1 9 � 7 as cited in Rawson . 2 0 0 0 : see eh. 2 5 ) .
• C l i n ical ' i n t u i tion ' Expert clinici ans someti mes explain t h eir clin ical deci sions on the basis of a ' g u t feel i n g ' or ' h unc h ' . which can be descri bed as a s trong feeli ng or perce ption about a patient or a n a ntiC ipated outcome sensed without obviously u ndertaking an analytical reasoning process. Th i s could be thought of as a refi ned or subtle form o f profeSSional j udgment: i n so me fields (par t i c u l a rly nursing ) , it is re l'er red to as ' intuitive' reasoning. Experts often have d i fficulty a r ticu l ating how they in terpret i ncomp lete and ambiguous d ata. draw inferences and identify implications that are not directly deducible from exp l ic i t data ( Higgs and Titchen . 2 0 0 0 ) . However. tacit knowledge can be l i nked to past experience of s pecific patient cases in simil ar co ntexts ( i . e. i t i s experie ntial knowledge) . and i s therefore probably the res u l t of an unconscious and a u tomatic form of in duc tive reason ing ( Higgs a nd Jones. 2 00 0 ) . I t a ppears that substan tial c l in ical experience. combined with a nd re l a ted to prior learning. is req u i re d for the development of tacit k n owledge and such adva nced reasoning. Cl inical 'intuition' can. therefore, be viewed as a form of learned awareness. pri nCipa l ly invo lving the process of pattern recognition. in which decisions and actions are la rgely a fu nction of tac i t know ledge. While a sign illcanl component of experts ' know ledge is tacit (Fleming and Mattingly. 2000). this know ledge also carries with i t a real potential for error bec ause. by v i r t u e of i ts su bconscious existence, it can escape the critical review from self-reflection to which more conscious knowled ge structures are sub j ected. If cli nicia n s can learn to exter nalize this tacit knowledge and inluitive thinking through c l i n ical rea soning activi ties. as descri bed below. errors that may
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I M PROV I N G C L I N I CA L R EAS O N I N G I N M A N UAL T H ERAPY
be present a re more l ikely to be recog nized and cor
enq uiry, interpretatio n . synthesis. p lann ing. and reJ1ec
rected . In particular. the use of peer lea r n i n g or coach
tion (Jones.
ing has been a dvo ca ted to e n h a nce reaso n i n g skills
cau ses o f c l i n i c a l reasoning errors:
(Ladyshewsky et al.. 20(0) through art icul ation or t h e c l i n i c i an ' s or learner's t houghts and dec i s i o n s . thus fa c i l i t a t i ng restructuring of know l ed ge ( Rege hr a nd Norma n .
1 9 9 6 : see Ch. 2 5 ) .
S i m i l a rly. some o f the enqu i ry strategies t h a t the ex per t cli nician em ploys may seem to be no more t h a n
unsubstanti ated 'short-cuts' or ' ru les o r t h u mb ' . giving the appeara nce that expert s ' c l i n i c a l reasoni n g is less than thorou g h . even s l oppy ( B a rrows and Tamb ly n .
1 9 8 0 ) . However. i n such cases. i t i s more t h a n l ike ly the expert is a p p ly i ng m a x i m iz i l lg princ iples-stra tegies t h a t red uce the n u mber o f questions o r actions neces sary to u nderstand a pr o b lem ( l<J einmu nlz. 1 9 ( 8 )-to
avoid wasling time explori n g every conceivable path
way. The u s e o f such strategies e n ables t he best q u a l i ty of information to be o b t a i ned in t h e most e fficient m a n ner, rad ica l ly red u c i ng t he problem environment
w i th e a c h question or procedure. M a x imizing princi ples can. there fore. be v iewed as maxi mizing t h e bene fits ( i . e . accuracy and effi ciency of decision making) and
minim izing the costs (i .e. the errort invol ved in gathering
' I
1 9 9 2 ) . Scott ( 2 000) h i gh l i g h ts th ree m a i n
• fa u l ty e l i cit a t i o n or pe rc ep t i o n o f c l i n i c a l cues
( d e ll c ient cli n ic a l
ski lls)
• i n a d equ a t e kno wl edge. for exa m p l e about
a
c l i n ic a l
condi tion (deficie n t propositional or profe ssion a l cra ft knowledge) • misapplication o f knowledge to a specifi c problem ( d e fi c i e n t reaso n i ng stra tegies ) .
These th ree ca uses of e r ror may wel l b e i n ter- rel ated .
Fo r instance, fa u l ty e l icitation
or percep t io n a n d inter
pre tation of cues can be related to i n a d eq u ate
know
ledge (both experi mental a n d experience b ased) of the re levan t c linica l cues or to u nderdevelo ped professional
cr aft knowledge i n recognizing those cues. S i milarly, mis a ppli ca tion of known facts to a specllc cl in i cal prob lem re l a tes to i ncorrect use of he u ri s ti c s , an example of poor proced ura l knowledge.
FollOwing fro m these causes, S c ot t ( 2 00 0 ) identifies three ma i n categories o f common reason i n g errors. Fo rming a wrong initial concept of the proble m (fra m
and a n a lysing i n formatio n ) requ ired i n solving a cl i n
ing e rro r) .
ical problem. T h e use or t hese princi ples is the privil ege
i n terp re t in itial or c r iti cal cues, they can form a n
If c l inicians fail to attend to or correctly
of the expert cl i n i c i a n beca use the a s s o c i a ted fo rwa rd
incorrect initial concept of the clinical p r o b l e m . This
reasoning is based o n d o m a i n know l e dge a n d i s , there
Gill
fore. highly error-prone in the absence of a n adequ a te
agement decisions being formwated . Significant time
resu l t in l1 a we d or in ad equa te diagnostic or man
k n o w ledge base ( Mech a n ic and Parson , 1 9 7 5 ; Pate l
wasted in pursuing erroneous lines of inq u iry, a n d
a nd K a u fman . 2 ( 0 0 ) a n d conti n u a l critical reflection
t h e im p l e men tation of ina ppropriate ( e . g . h armfu l .
) . Maximizing
wastefuJ or useless) treatments . This ty p e o f error
principles are. therefore. conti nually devised and revised
c an be avoided by spending time car efu lly checking
in the l ig h t of this criti c a l reflection on research- a nd
and interpreting cues (e.g. not overemphasizing pre
o n that
k no w l e d ge ( i .e.
m e ta co g n i ti o n
e x p e r i en c e - b a sed evidence ( Boud . 1 9 8 8 ; Rivett and
vious diagnoses or investigation results ) . q uestioning
Higg s . 1 9 9 5 ) . Ex amples o f maximizi ng p rinci p l es are
the validity of the emerging picture of the clinical
h i gh l i g h te d in the experts' case reaso n ing in S e c t i on 2 .
proble m and c l ar ifying rather than assuming patient responses (e.g. not accepting patients' use of medical terms such as migraine on face value).
C l i n ical reaso n i n g e rro rs
Fa i l u re to generate plausible hypotheses and to test them adequately.
Cli n ic i a n s
can miss cues, mis
Wh i lst c l i n i c a l reaso n i n g is conce ptu a l ly re latively
interpret clinical data (e.g. overinterpreting cues that
s imple, i n practice it i s q u i te difficult to perform effi
t hera py,
h ave l i ttle relevance, such as normal variations) or fail to take s u fficient i n formation into consideration (e.g. ignori n g the importance of n ormal or absent findings) ; as a result, they c an fa i l to generate sound
is to u nderstand and avoid errors in r e a so n in g . Awa re
diagnostic or man agement hypotheses. This problem
ness of potential errors in the rea soning process helps
is fu rther compou nded if the error is not detected
to promote critical reasoning. Errors may occur at any
or the process of testing hy potheses is a l so fa u l ty
stage of the clinical reasoning p r o c ess : perception,
( e . g . clinicians m ay seek to con firm in adeq u a te o r
ciently and e ffect i ve ly and it can be fraught with errors. A n essenti a l element i n learning to be a better clinica l
reasoner, and d eve l op i n g exper tise i n
m a n u al
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T H E O RY A N D D EV E L O P M E N T
Table 26. 1
Catego r i es of c l i n i ca l reas o n i ng e rrors
Category
C h aracteristics
Vagueness
The pu rpose of eva l u ation or treatment i s u n c lear, and th e re is i n s ufficient i nfo rmation to judge the wisdom of c l i n ical decisions
Na rrowness
Fam i l ia r a p p roaches that seem effective a re used without consideration of a l ternative methods
Rigi d i ty
Standard ized regimens of eva l uation and treatment are used routinely with l ittl e or no consideration of i m p o rtant differences i n i n d ividual patient needs and res ponses. I n addition, treatment reactions are not monito red to detect un expected resu l ts. Such practice may be appropriate for a preprofessi o n a l technician b u t not fo r a manual therapist
I rrati o n a l ity
C l i n ical choices are based on convenience, habit, s u bjective i m pressions and the word of , gurus' advocating spec ific techn i ques, rathe r than o n sound evidence
Wastefu l n ess
I nvestigati ons are exte n s ive. but the i r res u l ts have l ittle influence on treatment sel ection. Costly treatment tec h n i q u es are used without cons i d e r i ng whether more economical interventi ons might be equally effective . C ritical reflective reas o n i ng about c l i nical experience and available research evidence s h o u l d m i n i m ize this erro r
I nsensitivity
Patients' and fa m i l ies' personal va lues and psychosocial concerns are ign o red, and phys ical performance i m p rovement is given h igher priority than enha nced q u a l i ty of I ife . T h i s is bas ical ly not u s i ng narrative reason i ng and associated c o m m u n icative management to attend to patients' pain experiences (Ch. 1 ) The c l i n i c ia n 's process of decision making cannot be exp l a i n e d i n te rms patients and colleagues can
Mystery
und erstand, and so oth e rs cannot q u esti o n and contribute to th is process
From Watts
(1 995).
erroneous hypo theses or m ay test hyp o the se s insuffi
sel f-e v a l u a tion by t h e c l i n ic i a n a n d constructive and
ciently) . Attend ing to both supporti n g a n d negating
accurate fee d b ack by
ev idence and d isprov i n g hy p o the se s
rather than
p reve n t reasoning errors becoming habit. Wi thout
assu m i n g that evidence supporting one hy pothesis
th is cognit ive vigUance. reaso n i ng errors can rema i n
-
a
peer o r mentor are essen tial to
imp l i es that compe t i n g hy potheses are n o t val id
u n d e tected fo r s o m e time a n d res u l t i n i neffective,
will assist in avoid i n g this type of er ror. Co nverse ly.
e v e n h azard o u s , cl inica l i n terve n tions.
or
clin ici ans may overu tilize hypothes i s testing. maki ng
To avoid r e a so n i ng errors in your ow n c l ini c a l prac
j u d gments on their o wn when consensus v a l id
Lice, it i s i m p o r ta n t to ta ke ' time-out' to reflect on you r
.
a tion with the patient is c a l led for, as w i th narra
c l i n i c a l reaso n i n g a nd seek a ny evidence o f e r rors i n
tive reasoning j u d g ments regard i n g the patie n t ' s
yo u r dec i s i o n mak i n g. Pas t cl i n i c a l experience may
persona l perspective o f their p a i n experience. Inadequate testing a n d p re m a t u re acceptance oj
prov ide you w i th s p ec i fic ex amples where you have committed an er ror, as de s c ri b ed above. Co n s ider how
Problems c a n a rise when c l i n i c i a n s
the error was detected ( i . e . by you o r by someone else)
prematu rely accept hypoth e se s ( e . g . they may a d op t
and what consequences a rose because o f t he er ror In
favoured , c o mmon or obv ious hypotheses) a nd then
particu l ar. look o u t for the s pe c i fic errors i n your own
d ur i n g the tes t i n g process fa i l to detect that an error
clinic a l
in re aso n i n g has occurred bec a u se they a re expect
1 9 9 2 ) as o u tlin e d
hypot heses.
.
ing the hypothesis to be c o n firmed . I n a d d i tion .
r easonin g (Ch ri s te n s e n e t al. . 2 0 0 2 ; Jones, in Ta b l e 2 6 . 2 . A s c a n be seen in th e table, errors in clin ical reaso n i n g are fre quen tly related
confirmation bias can result when cl i n i c a l cues
to errors in cognition , includ i n g a n aly si s an d synthesis
a re selec tively chosen o r i n terpr ete d as v a l i d ating
o f d a ta and use o f enqu iry ski l l s . These errors
favoured hypotheses.
Critical eval u ation
o f hypoth
esis testing processes an d consequent clinical fmdings
will a lso
W<ely contrib ute to the development of poorly organized knowled ge, thus compou n d i n g the pro blem.
is important to prevent this type of reason ing fault. Common c l i n ical reasoning errors have been fu rther
C reative , l ate ral th i n ki n g
c a t ego r ized by Watts ( 1 9 9 5 ) ( Ta b l e 2 6 . 1 ) . I t is c l early important for c l i n i c i a n s to avoid c l i n
Historically. the new ideas and si g ni fi c an t contri bu tions
ic a l re a s o n i n g errors d u r i n g c l i n i c a l practice . Cr i t i c a l
in m a n u a l therapy have genera l l y come [rom a sm a ll
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26 I M PROV I N G C L I N I C A L REASO N I N G I N M A N UA L T H ERAPY
Table 2 6 . 2
Common c l i n ical reaso n i ng e rrors
Activity
E rrors
I nformatio n collecti on
N eglecting i m portant i nformation or fa i l i ng to sample enough i nfo rmation M i s i nterpreti ng information or making ass u mptions without cla rifying Basing decisions o n insufficient evidence Ove remphasizi ng either biomed i cal ( p ropositional) o r c l i n ical (no n-propositional) knowledge and evidence Fa i l i ng to d etect i n consistencies i n the c l i n ical presentation
Hypothesis fo rmation
Focussing too much on favou rite (or obvi ous) hypotheses Only attending to, or overemphasizi ng, those featu res of a p resentation that s u pport a favou rite hypoth esis. wh i le n egl ecting negating featu res (confi rmati on bias) ConSidering too few hypotheses o r not testing com peting hypotheses Prematurely l i m iti ng the hypotheses considered Formulating non-s pecific hypotheses Not considering hypotheses in othe r categories (see ' hypothesis catego ries' i n Ch.
1)
M i s i nterpreting non-contributory i nformation a s confi rm i ng a n existing hypoth e s i s Reaching fi rm d e c i s i o n s p re maturely I dentifying vital cues (flags)
M issing contra ind ications or p recautions to exa m i natio n or treatment Fai ling to detect cues i n d i cative of serious pathology o r l i n k the cues to hypotheses
Diagnosis
Overemphasizing c l i n i cal fin d i ngs that are m i n o r i n the context of the whole patient presentatio n M is d i agno s i ng M i s S i ng a relati o n s h i p between symptoms or confusing a re lati o n s h i p betwee n symptoms a s confi rm i ng c a u s e and effect Confu s i ng a n d inappropriately applying deductive and i n d uctive l ogiC, lead i ng to i n co rrect i nte rpretations
Treatment
Taking u nwarranted action Fa i l i ng to mon itor you r own reas o n i n g (meta cognition) U s i ng c l i n i cal 'recipes" not clin ical reasoning ( i . e . b l i n d ly fo l l owi ng treatment p rotocols) Fa i l i ng to i nvo lve the patient i n decision making Not tak i ng i nto account the context of the patient's problem or its i m pact on the i r life
number of individuals and often more than one sign ifi cant contribu tion has come from the same i n divid ual. Clearly, there a re many reasons for this, including prev ious education and experience. external work constraints and genetically in fluenced levels of intelli gence and thinking styles. While these factors may be lar ge ly out of our control. Edward De Bono ( 1 9 7 7 , 1 9 9 3 ) . a pro l i fi c writer o n the topic o f thinking and lateral thinking. argues that creative, lateral th i nki n g can be promoted by maki ng people aware of their curren t think i n g processes and encouraging the practice o f looking a t old patterns in new way s De Bono distingu is hes between 'vertical ' and ' l ateral ' think i n g with ver tical thinking bein g c h ara c ter ize d by logical . sequential. predictable and what might be called conventio n a l thinking. Latera l thinking. by compari son, involves restructuring and escape from old pat terns and creation o f new ones . It is concerned with the generation of new ideas a n d looking at things in a .
,
different way; vertical th ink i n g is then concerned w i th proving or d eveloping these new ideas. Wh i l e vertical thi nki n g is hindered by the necessity to be rig h t or ' logica l ' at e a c h stage of the thought process, l atera l thinking m a i nta i n s that premature formalization and expression o f a n idea may i n h ib i t its natural deve lop ment. In vertical th inking, one selects out only that i n formation considered relevant; however, in latera l thinking one may deliberately seek out irrelevant infor mation because this i n form ation may assist in v iewing a problem from a d iffere nt perspective and as such con tribute to promotin g a di fferen t view. The clin ical reasoning literature across the health professions, including manual the ra py has highlighted the expert's ability to recognize patterns. This can be attributed to superior organization of lmowledge in t he ir particular area of practice. Efforts to facilitate learners ' organ izaLion of knowledge in manual therapy education have arguably contributed to this pattern recognition
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,
T H E O RY A N D D E V E LO P M E N T
s kill by teachin g learners the cl assic c linica l patterns of
o n ly t h i ngs that appear to be relevan t are consid
presentatio n . It is worth considering whether encourag
ered, the current pattern w i l l be perpe t u a ted
in g learners to identify clinical patterns might not lead to
• ex plore the least like ly paths
a n a r row form of reaso n ing, whereby problems are
• chal lenge the assumptions of current thi nking;
forced into discrete sets or ' b l ack and white ' patterns, a
sometimes a prob lem cannot be solved by trying
situation that rarely occurs in actu a l clin ical practice.
d i ffe rent a r r a n ge me n ts 0 (' the g i ven p a r ts b u t only
Such
by re-ex a m i n a t i o n of the parts themse lves
an
overly focussed view of clinical patterns can
tend to mal<e these ri gidly established. si nce i t is the pat
• suspend j u d g me n t ; do not b e too q u ick t o dismiss a
ter ns that control our attenti o n . Other disad vantages o f
seemingly i n c o r rect idea as i ts exploration may lead
overattenillng t o patterns include:
to the correct idea
• d i fficulty in c h a n g i n g patterns once they h ave
become estab l i s h ed • restri c t i n g cog n i t ively the ava i l a b i l i ty of i n forma
t i o n : i n formation arranged as part o f one pattern cannot easily b e used as part o f a compl etely d i ffer e n t p attern • te ndency towards ' ce ntri n g ' , whereby anyt h i n g
t h a t has a ny resemblance to a standard p a ttern will be perce ived as part o f that p a ttern • creating p atterns by d i v i s i o n s that are more o r less
a r b i trary ( i . e . dividing what is continuous i n to d is tinct u n its) ; o nce such d i v i s i o n s are crea ted they
• perhaps most i mporta n tly. recog n i z e the d o m i n a n t
ideal a pproach. To prom ote your o w n creative. l a teral t h i n k i n g you must fi rst be ab l e to recog n i z e the d o m i n a n t i d e a or approach you a re presen tly ta k i ng towa rd a pro b lem. W i th o u t th is, a ny new idea yo u tri a l w i l l only be a v a r i a tion on the same theme. Once yo u recog n i ze the dominant t heme to how you have approac hed a prob lem , you c a n then l o o k o u tside that to d i scover alter n ative id�as o r s o l u t i o n s . The dominant ide a does not reside in the situatio n i tself but i n the way you look at it.
become self-perpetu a t i n g . O ne way t o gai n t h e benefits of patter n recogn ition whiJ e controllin g for these risks is to ensure that teachin g facil itates learners' acquisition and organizatio n of lmow ledge with equal and simu l taneous attention to a reasoni n g process that enables know ledge to be chal lenged and tested. In this way, learners acqu ire not only the c l assic presen tation of common problems but also an a ppreci ation of the ty pical overlap that exists between many clinical patterns . In adilltio n . they develop critical and reflective thinking habits. which ensure that pat terns are continually tested and new patterns sought. Never t h e less . this c r i tic a l . hy pothe tico-ded u c tive mode of reasoning will not n ecessarily contrib u te to the development of truly nove l . creative ideas . For this . we support De Bono 's view that learners should be exposed to lateral thinking strategies. Some of De Bono's s trate gies to promote creative, lateral t h i n k i n g are : • i n s tead of stopping when a promising approach to
Activities to i m p rove c l i n i cal � reason i ng There are m a ny learning activities a n d rel a ted tools that the manual therapist can use to enhance the deve l o p m e n t of cl.inical reason ing s k i l l s . Ideal ly, these should encompass the i n terdependent components of know ledge. reasoning abil i ty and metacogni tion ( Refsha uge and Higgs,
2 00 0 ) . Indeed, studies of experts h ave
shown t h a t d o m a i n knowledge a n d the associated skil ls to use this know ledge d evel o p S i mu l taneously (Boshuizen and Schmidt,
2 000). Lear n i n g experiences
s h ou ld. therefore. promote active i n te g ra t i o n of cog n i tive processes and knowledge derived fro m c l i ni c a l experiences i n to the c li n ic i a n ' s o r l e a r n e r ' s ex i s t i n g knowledge str uctures , cons istent with learning the ory ( S h epard and Jense n .
2 00 2 ; see Ch. 2 5 ) . Newly
acqu i red know ledge should be tested for its consis tency
n il a ny identi fi ed gaps
a problem has been fou n d . c o n t i n u e to generate as
a n d connectedness and used to
m a ny a l te r n a tives as possi b le
in pre-ex isting knowledge . To achieve t h i s , the practi
• i n stead of a lways moving usefu lly in one direction,
tioner must try to find the time to learn fro m cases,
p l ay a ro u n d w i th n o spec i fic p u rpose other t h a n to
whether i t be i n c l i n ical practice or in c l i nical simula
see its effect, which may, i n tu r n , be a s t i m u lus to a
tions, and c arefu l ly reflect upon these exper iences . As
di fferent i d e a
was argued i n Chapte r 2 5 . ex perience and reflection
• welcom e o u tside. seemi n gly ir relevant. information
as a potenti a l stimulus for a l te ri n g a p a tter n ; if
must be connected for lear n i n g to occur i n the complex and busy clinical s i t u a t i o n .
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I M PROV I N G C LI N I CAL REASO N I N G I N MANUAL T H E RAPY
,
C l i n i c i a n s seek i n g to promote the develop m e n t of
• using a b roadened perspective b eyo n d d i ag n o s t i c
their own c l i n i cal rea soning ski l l need to be cog n izan t of
reaso n i n g ( i . e . hypothes i s ca tego ries. as d i scussed
the ad ult le a r n i n g pri n c i p les di scussed in Chapter
It is
25.
i n Ch .
I)
i mperative th a t c l i n i c i a n s d o n o t adopt a pass ive .
• ide n t i fy i n g relev a n t cues a n d th e i r s i g n i fi c a nce a t
' s po o n - feed i n g ' a p proach to lear n i n g : t h e y s h o u l d b e
t h e b e g i n n i n g o f the p a t i e n t e n c o u n ter. t h u s fa c i l i
actively e ngaged i n t h e man ageme n t o f their lear n i n g
t a t i n g accuracy i n hy pothesis gen e r a t i o n a n d reap
experience. a s wel l as t h e le a r n i n g process itse l f. Deep.
ing m a x i m a l bene fit fro m re la ted i nq u iry s tr a tegies
mea n i n g fu l learn i n g s hou ld be fo stered . and this c a n
• m a k i n g g reater use o f e n q u iry s t r a te g ies to prove o r d i s p rove hypot heses (i . e . hy pothesis test i n g )
o n ly b e b ro u g h t a b o u t b y the employme n t of h igher o r adult learn ing ski l l s . i ncluding sel f-d irec tion a n d critical
• ma k i n g m o r e ex plicit a t te m p ts t o u n ders t a n d e a c h
(i.c.
self-apprai sa l . and by see k i n g appropri ate k n o w l edge.
p a t ient's u n i q u e p a i n e x p e r i c n c e
feedback a nd help. c o n s i s tent with the pre v i o u s ly
reas o n i n g ) . w i t h i mpress i o n s v a l i d a ted t h rough
espoused principles of h uman istic edu cation . Clin ic i ans must accept res pons i b i l ity fo r m a n a g i n g the i r own
n a r rat ive
patient-c l i n i c i a n c o n se n s u s • improvin g t h e d e p t h a n d orga n ization o f kn owledge :
lea r n i n g a n d le a r n i n g outcome s . i n addition to sel f
attend i n g t o broader m o d e l s o f hea l t h a nd d i sabi l i ty
mo n i tor i n g their l e a r n i ng. It is impor t a n t to recog
(Ch.
n ize that all these key elements of sel f-directed l e arn in g
c l i n ic i a n s ' d e ve lopment o f contempora ry and c l in
( see ' Se l f-directed lear n ing ' i n
Ch .
2 5 ) are facil i ta ted
I)
a n d u s i n g hypo t h e s i s catego r i e s may assist
ica lly applicable k n o w ledge
t hro ugh skilled c l i nical reaso n i ng. as similar cogni tive
• re flecting regu l arly about clin ical experiences : c l i n
processes a n d behav i o u r s a re req u i red fo r b o th s e l f
ic a l experience withou t rei1ec t i o n w i l l not fac i l i tate the a p p l ication of ava i l able e v i d ence o r t h e d e ve l
d i rected ( a d u l t ) l e a rn i n g a n d c l i nical reaso n i n g . Ski l ls i n cl i n ica l re a s o n i n g c a n be fostered thro u g h
o p me n t o f profeS S i o n a l c r a ft k n o w l e d g e a nd rea
the use o f a d ult l e a r n i ng p r i n c i p l e s . wh i c h h e i g hten aware n ess of c o g n i tive errors a n d kn owledge gaps .
son i n g expertise.
The a p p l i c a ti o n of these princi ples i n c l u d e s :
Rellection s ho u l d
• rel a t i n g new cl i n i c a l c o n cepts a n d experiences t o
•
prev ious k n owledge • re l at i n g
the
c l i n i c a l and research e v i d ence to the
i n c l ud i n g t h e i r basis • any specific interpretations and j u d gments ( hypoth
• cri tica lly examining t h e logic o f reason ing processes the
deeper
prinCi ples a n d con
cepts u n derly i n g m a n u a l therapy assessment a n d
eses) m a de • a ny s u p p o r t i n g / negati ng ev idence fo r d e c i s i o n s • t h e di fferent fo cus o f d e c i s i o n m a k i n g req u i red (see discus s i o n of c l i n ic a l reaso n i n g s trategies
m a n a geme n t • deve l o p i n g s k i lls i n l i fe l o n g pro fess ion a l l e a r n i n g • co m m u n i c a t i n g reason i ng a nd j u s ti fy i n g c l i n ical
in
Ch . 1 )
• whether your k n owled ge (propos ition a l a n d n o n propositi o n al) i s sufficient to u nderstand a n d to
decisions • u n d e r t a k i n g re g u l a r rei1ecti o n (both d u r i n g and a fter the lea r n i ng or cli n i c a l experience) • developing aware n ess of one's cog n i t ive processes . incl u d i n g
re l i ab i l ity a n d va l id i ty o f i n fo r m a t i o n o b t a ined
• p a t i e n ts ' perso n a l pers pective s or pain experiences.
d ec i s i o n s m a d e • u n dersta n d i n g
t he
i nc l u d e th i n k i n g ab o u t :
s e l f-mo n i tori n g ,
self-e v a l u a ti o n
and
co n trol ( metacog n i t i o n ) • see k i n g a n d acti n g on feedb ack abou t c l i n ical perfo rmance.
In addition, the deve l opment o f ex pertise in c l i n ical reason i n g c a n be promoted through the use of the fo l l owin g strategies:
help the patient a nd problem i n questi o n . Much of t h i s rei1ection is i n herent i n the c l i n ic i a n s ' a n swers to the reason i n g q u es t i o n s p o s e d throughou t Sectio n
2
a n d s h o u l d a l so be used by readers a ttempt
i n g to a n s wer the questions themse l ves when work ing through a case. Ide a l ly, the clinician should u nd e r ta ke a lon g-term formal postgraduate course in manual therapy that has a strong e m p h a sis on s u pervised c l i nical practice a nd clinical reasoning. W here this is not fea s i b l e , t here are
• i ncreas i n g awa reness o f reaso n i ng processes and
a va riety o f a c tiv ities t h at the cli n i c i a n can under take
reasoning errors . which helps to make the clinic ia n ' s
to promote the development o f their reasoning skill and
i nter n a l co g n i tive processes more accessible
which active ly engage the l e a r ne r in thinking a n d
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I'D
T H E O RY A N D D EV E L O P M E N T
dOing. Learning activities should preferably provide a n
n eed to be pro active in seek i n g out
opportu n i ty for feed b ack and reflection an d encourage
m a nu a l thera pist to act as their mentor(s ) . Mentors
appropriate
critical debate, experimentation, open-mindedness a nd
s h o u ld not only possess attributes of c l i nical expertise
an
i n tellectu a l curiosi ty. Dur i n g these activ i t i e s , man u a l
and b e good role models but s h o u ld also be tolerant of
therapists should consciously str ive to iden tify a ny defi
mistakes, ca pable o f openly communicati n g th eir own
ciencies in their knowledge structu res a nd i n crease
t h i n k i n g and wi ll i n g to prov i de construc tive feedback
In
their awareness of their cognitive processes (metacogni
and clirection ( L e . not necessarily all the a nswers ) .
tion ) . Experts not only know a good d e a l in t h e i r area
add ition , consistent w i th the a i ms of human istic edu
2 5 , mentors should strive
of special interest, they also recognize wh a t they do not
cation d iscussed i n Chapter
know a n d are ever ready to seek fu rther k nowledge
to create (or help the learner create) a highly supportive
and evidence from the l i terature and through consult
a n d accepting lear n i n g environment, w h i c h is con
a t i o n with colleagues.
d ucive to the ind ivid u a l learning and applyin g clinical
In selec ti n g a n activity that fosters deep l e a r n i n g ,
reason i n g . The clinician see k i n g mentorship must, by
manu a l therapists shoul d take in to consideration their
the s a me to ke n , be w i l l ing to express their professional
individual lear ning styles, the learning setting and their
craft knowledge and cli n i c a l reaso n i n g , as well as
stage o f reasoning development. Readers are encour
readily accept feedback. That is, lear n ers must be will
aged to review the descriptions o f learning styles from
ing and able to take a responsible a nd self-directed
the d i fferent le arning theories presented i n Chapter
25
a nd attempt to identify characteristics they feel best describe
themse lves .
Commonly,
i nd iv i d u als h ave
role in their own lea r n i n g . K nowledge i s m a d e p a r t i c u l a rly mea n i n gful and access i bl e when it is a cq u ired in the con text in wh ich
s trengths in some lear n i n g styles while b e i n g weaker
i t w i l l be utilized (see ' S i tu ated learning' i n C h .
in othe r s . S u c h sel f-reflection can assist readers to
Initially i n lea r n in g activities , c l i nicians s hould be
become more aware of their ' we a knesses ' , which may
exposed to ty pical cases (Le. textbook presentations) ,
p a r t ly u n der l ie any reasoning bias they have; s u c h
with a typical presen tations i n trod uced as their level
2 5).
2 0 0 0 ) . In
self-knowledge assists i n broaden i n g perso n a l learning
of exper tise war r a n ts (Hayes and A d a m s ,
style and hence poten t i a l to learn .
add i tion to a co l league ( m e n tor o r peer) m a k i n g com
• C l i n ical p ract i c e
borne in mind that the patient can also provide i nvalu
ment u po n the clinician 's decision makin g , it should be
A s described i n Chapter
able feedback. There are several activities to improve
2 5 , it i s desirable t o employ
learning activities that facilitate s i t u a ted learning: th at
c l i n i c a l reaso n i n g t h a t can be u n derta ken
with
a
mentor or peer u s i n g real p a tients.
is, l e a r n i n g u nd e r taken in the c o n text where i t will be used. Pa tients are the best resource for l e arning and
Demonstrating all assessment of a pa tie nt
.
The clini
develo ping reason i n g expe r tise ; however, the clinician
cian assesses and
needs to be ope n - m i nded a n d willing to think ab o u t
observed by a mentor; aJternatively, the mentor can
treats a patient whi le being
the clin icaJ encou nter. Importantly, t h e use of a men tor
assess and treat a patient while being observed by the
2 0 0 1 ) in the l e ar n i n g
clin ician . Two peers of equal rank can a lso be
or critical companion (Titche n ,
p rocess h a s been s h o w n to be instrumental i n the
involved (reciprocal peer coachi n g ) . In al l instances ,
1999; Jones, 1 9 9 9 ; Mar t i n e t a I . , 1 9 9 9 ; Titchen , 2 0 0 1 ) . Indeed , research b y Jensen e t a l . ( 1 9 9 9 ) h a s demon
discussion can occur either throughout t h e patient
developme n t of c l i n i c a l expertise (Jensen et a I . ,
stra ted the val ue o f practising i n the presence o f o ther c l i nic i a n s , who help to g u i d e and refine thinki n g and
encounter, i n the form of evolving thoughts , or as soon as possible after the patien t enco u n ter. Colla borative assessment.
S h ared and collaborative
assessm e n t a n d trea tme n t i nvolves explicit discus
re a so n i n g processes ; this is the 'cognitive appren tice
sion of plans and thou g h ts ; open-ended q u estions
s h i p ' approach referred to i n C h apter
2 5 . S i m i larly,
a re regula rly a sked or one a n o t h er. O p t i m a l l earn
refer red to reciprocal peer
ing requires such soci a l i nteraction and c o l l abora
Ladysh ewsky et
a!. (2 000)
c o a c h in g , which i nvol ves demonstra tion , observation .
tion (Lave ,
1 9 9 6) .
coll aborative practice, feed back and discu ssi o n , a n d
The use of a reflective d i a ry of cli n ical patte rns.
p r o b l e m s o l v i n g w i th a peer. Consiste n t w i t h tak i n g
This facilitates skills in pattern recogn ition by record
resp o n s i b i l ity for t h e i r o w n lear n i n g . cl i n icians may
ing typical pattern reatures ( i nc l u d i n g associ ated
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26 I M PROV I N G C L I N I C A L REASO N I N G I N M A N UAL T H ERAPY
,
m a n a gement principles) a n d by comparing simila r
and reaso ning i s thus clearly demonstrated to the clin
patterns ( see Appendix 1 for an example) . In p a r
i ci a n . In additi o n , by receiv i n g i m m ed iate, spec i fic
ticu l a r, features that are shared by several p a tterns
and constructive feedback on t h e ir evo l v i n g thou ghts
and featu res that may vary with i n a specific pattern
and decisions, cli n icians a re ab l e to modi fy their rea
c a n be highl i g h ted . This learning tool also primes
s o n i n g during the case consistent with that o f the
the practitio ner to look lor i n formation to add to
expert, rather than sim p ly being ' corrected ' in hindsight
their evolving diary, for exa mp l e during c l inical
(Prio n , 2 000) . Final ly, by h av i n g to communicate their
practice, and provides a stimulus for i ndependent
thoughts, arguments and ratio n a l e for c l i n ic a l d eci
study, such as review i n g ava i l able evidence to sub
sions, clinicians are req u ired to clearly u nderstand and
stanti ate or challenge the c l inical patterns identi
organize their own lmowledge an d its use, and to recog
fied ( C a r r et a I . , 2000; Sackett et a I . , 2 00 0 ) .
nize the adequacy of their k n owledge base ( Refs h a u ge
T h e thoughts of t h e clinician or the mentor/ peer can b e m a d e explicit a n d accessible t o the other i n several ways: • ' th i n k i ng aloud' ( i .e . real-ti me a r t i c u lation of their
thoughts) while so lving the patient problem • using verbal stimulus questions to help access rea
soning processes . but this must be done i n a m a nner that does not erode either the cred i b i lity of the clin ician i n the eyes of the patient or the clinici a n ' s confi d ence • usi n g strategica l ly p laced pauses at key stages of
the exa m i nation and treatment to encou rage the c l i n ician to i n terpret fi n d i n g s , formulate and j us tify hypoth eses , identify enqu iry strategies to val i d a te hypot heses , and to consider interve n t i o ns • i n terrupting by the mentor if the clinicia n follows an
i n correct or unsubsta ntiated line of enquiry;
this should be b a l a nced with the need lor the clini cian to experience t h e resu lts of his/ her own e n q u iries a n d reaso n i n g • con tinui n g d iscussion abo u t t h e c l i n i c i a n ' s reason
ing after the patient encoun ter, which can further help i n fac i l itating rellective learning.
a nd Higgs , 2 ( 0 0 ) . Self-reflection worksheets , s u c h as t h e C l i n i c a l Reas o n i n g Reflection F o r m (Appendix 2 ) , c a n a l so be used to prompt and record the clinician 's thinking processes. Relevan t sections of the form are completed at key points, such a s a fter ta k i n g the history or j ust prior to the first treatment. These periods of ' time-out' e ncourage the cl i n i c i a n to review a n d reflec t o n the cl inical data, as we ll a s plan for future action. T h e for m may also be checked for accu racy and complete ness by the mentor. Initi a l ly, completion of the e n tire form is hel pfu l to identify areas o f enquiry, reaso n i n g a n d a ssoci ated lmow l e d ge where t h e l e a r n e r could i m prove. Then , a s the learner demonstrates consist ent competence with d ifferent section s , they can be requested to only complete those sections where fu r t her practice with a d d i ti o n a l patie n ts and varyi n g presen t a tion s is considered benellci a l . In a d d i tion , the mentor can provide general written feedback through o u t the patient encounter for l a ter cons iderati o n . particularly w h e n i t is u n desirable to i n terrupt the clinici a n ' s reasoning. It should be noted that the exam ple rorm in Append ix 2 will not s u i t a l l l ea rners a n d , therefore, students a n d practitioners a re encouraged
It is importa nt t h at an i n formal contract is negotiated
to develop their own for m to meet the i r own c l i n i c a l
beforehand to deli neate the extent and method o f s u c h
reaso n i n g (reflection) needs and lea r n i n g situa t i o n .
d iscussion ( Carr et al . , 2000), particu larly i f t h e mentor
A n a logous t o self-re flection worksheets , computer
i s goi n g to i nterrupt. The m a ny benefits of peer lear n
software for patient in formation record i n g i s n ow
i n g that i nvol ves co ll aborative decision making a n d
ava i l able with rellection prompts to sti m u l a te the
feedback li'om peers are d iscussed i n C hapter 2 5 i n
cli n ic i a n ' s reason i n g ( e . g . Adoc Services Lie. , 2 0 0 2 ) .
t he sectio n o n 'Peer lea r n in g ' .
Learning from one's c l i n i c a l practice, th at i s work
Clinical lear n i n g activities i nvolv i n g a mentor offer
b a sed lear n i n g , requires rea l e ffort on the part of the
several important bene fi ts to c l i ni c i a n s striV i n g to
clinician to integrate the inmlediate, practical demands
i mprove their reason i n g expertise. The modelling of
of work with the n eed to lear n from the d a i ly experi
exemplary decision m a king by mentors, in which their
ences involving patients and their pro blems . The
thinking processes are articu lated and their interpret
reader is referred to the section on 'Lifelong lea r n i n g '
ation of the pro b lem is explicated , provides a framework
i n Chapter 2 5 rega rd i n g the i mporta nce o f cu ltivat
for compa rison w i th the cli n i c i a n ' s reaso n i ng. The
Lng a work environ m e n t that encourages o n go i n g
relevance, depth a n d comp l ex ity of expert knowledge
learning.
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T H E O RY A N D D EV E LO P M E N T
• C l i n i cal
t e r t i ary e d u c a t i o n sector. it is q u i t e
s i m u l ati o n s
Rea l or hy p o t h e t i c a l c l i ni c a l p ro b l e ms c a n be pre se n te d i n a variety o f fo rm a t s that s i m u l a te the c l i n i c a l s i t u a t i o n . Cl i n i c a l s i m u latio n s can prov i d e a r ea l i s t ic and less-threate n i ng forum for the identification and cor rectio n of re a s o n i n g errors a nd t h e d e velopment of metacog n i tive skills. C l i n ic a l reas o n i n g activities that i n volve cl i n ic a l simu l ations can be u nd e r t a ke n i nd e p e n d e n t ly or w i th a me ntor or peer. Reso u rces for clin i cal s i m u l a t i o n s i nclude:
or men tor to role p l ay
or their
feasible for a peer the cl i n ic a l prese n t a t i o n o f one
p at i e n t s .
Pape r- based and oral cases Case reports are a v a i l a b le
in m a ny p ro fe SSi on a l j o ur
n a l s ( e . g . M a n u a l Therapy ) a nd books ( e . g . S ec t i o n 2 of
v i s u a l a nd a ud i t o r y cues. T he tape can a l so be rep l ayed
the present t ext ) and ar e o ft e n p r ese nte d by c l i n icians at in-service or o th e r professional meetings. Be tter case r e p o r ts d escribe the cl i n ica l reason i n g u t i l ized by the r e p or t i n g practitioner. They also attempt t o engage the r ead er or listener ac t i vel y by i n t e rs p e r s i n g q uestions throughout the c l in ical fi ndi n g s to s ti m u l ate the reader/ l i s t e n er ' s knowl e d ge a nd reasoning p r oce s s e s . S t o ry tel li n g by c l i n i c a l experts is a n o t h e r fo rm o f oral case p r ese n ta t i o n i n which they r e fl e ct on and i n t e rpret their own ex p e rie n ces , w ith the o p po r t u n i t y p ro V i ded for questions from o th er s . W h i l e there is no best fo r m u la fo r how to c o n d u c t these c a se reports. va l u able d is c u s s i o n c a n e m e rg e by pr ese n t i n g c h u nks o f the u n fo l d i ng patient i n formation fol l owed by discllssion of w h a t i s c o n s i dere d key i n l'orma tion ( p e rce pti on of r el e va n t i n formation represents one of the e a r l i es t c o g n i tive tasks i n c l i n i c a l r e a so n i n g ) . i nc l u d i ng how
for c l a ri fi c a t i o n and close ex a m i n a ti o n of c r i t i cal parts
d i ffe r e n t i nd i v i d u a ls in the d i s cu ss i o n wo u ld inter pret
of the p a t i e nt e n c o u n t e r.
or syn thesize that i n forma t i o n . The hy p o t h es i s cat
• v i d eo t a p e s • i n teractive c o m p u t er p r o g r a m m es
• s i m u l a ted p a t ie n t s •
p a per- b a s e d a n d o r a l cases
Videotapes Vi de o t a p es are r e c o rd i ng s of re a l o r s imulated patien ts being i n terviewed , a ss e s se d and treated. They are c o m m er c iaUy available (e.g. Maitla n d . 1 9 9 9 ) or can be pro duced by c l i n i c i a n s
i n the wo r kp lac e . Video ta pe d cases
lend t h e m s e l ve s to both gro u p act i v i ties a n d i n d e p end ent s tud y and
have the obvious a d v a n tag e of p rovi din g
egories p re s e n te d in C h apt e r 1
I nte ractive c o m puter p rogram mes Self-i nstructional compu ter programm e s can presen t real-life o r hy p o t h e t i c a l c l i n i c a l scen a r i os by u s i n g text a n d v i deo a n d a u d i o
p r o v id e one means of
d ir e c t i n g the foc u s o f t h e se d iscussions o f i n terpret ation. Imp or tantly, such discussions should also explore
the c l i n i c i a n s ' evidence fo r th eir in terpretations, be i t c li n i c a l o r research
b ased .
c l i p s . C l i n ical reaso n i n g q u es tions designed to elicit t h e cli n i c i a n ' s t h i n k i n g , a n d ex p l o r e t h e i r u n ders ta n d i n g a n d k n owledge, may also
tive tool fo r b u i l d i n g cogn i tive schemata. which are
be included. Vary ing forms or feedback and resource
(Prion, 2 000).
information into existing k n o w l e d ge s tr uc t u res ( C h r i s t i e e t a l . .
or group l e arnin g using case reports i nclude:
direction fa c i l itate the in t e g r a ti o n of n e w 2 0 00; Schneiders a n d R ivett, 2 0 0 0 ) .
• re a d
2) i s a n effec
tra nsferable to tbe rea l c l inica l co nte x t Some possible ac t i vi ti es l'or inde pe ndent
a
se c t i o n of a case r e p o r t ( e . g . the hi s t o ry ) and
j u s t i fy why this i n form a t i o n might be h e l p fu l • fro m an actu a l p h o t o g ra ph of a patie nt or the
A simulated p a t i e n t is a h e a lthy person tra i ned to por tray the h i s to rical, p hys i c a l , social a nd e m o t i o n a l fe a
tures o f a n a c t u a l patient. The a b i l i ty to t a ke u n l i m ited
out' [or d i s c u s s i o n
d i r e c t ly
in S e c t i o n
ide n t i fy any i n formation that was ' m issed ' and
S i m u lated pat i e n ts
' t im e
The wr i t te n case report (as
with peers and se l f-rel1ection
is an important a dva n t a g e
of using simu l ate d patients.
In a d d i t i o n , t he s i m u l a te d p a t i e nt c a n p ro v i d e s p e c i fi c fe ed back o n the cl i n i c i a n 's perfor mance from the per spective o f the patie n t . While i t m ay be dimcult to
access a pro p e r ly tra i ned simu l ated patient outside the
p a t i e n t ' s first co mme n ts (rom the interview, attempt to i d e n t i fy the releva n t cl i n ica l cues a n d p os s i b l e interpretations ( i . e . your in itial perceptions and hy p o the s es ) • u s i n g the main fi nd ings from the patient exa min ation . d e c i d e upon a tre a t m e n t and provide the reasons behind the de c i s i o n • re a d the p hy s i c al ex a mi n a t i o n I1 nd i n g s of a case a n d hy p o t h es i z e about the l ike ly h istory that might
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.
26 I M PROV I N G C LI N I CAL REASON I N G I N M A N UAL T H E RAPY be exp ec te d with s uch a presen t a ti o n . then com
be m a tched to the c l i n i c i a n ' s level of expertise. For
p a re your expec tations to the a c t u a l case h i story
ex a m p l e , a n o v i ce c l i n ic i a n
m i g h t commence w i t h
• co n s i der the assessment a n d m a n a gement decisions
mo re stra igh tfo rward a n d s h orter c a s e sce n a r i os a n d
made in the case aga i n s t your own c l i n ic a l experi
progress to more c o m p l ex a nd t ime-con s u m ing scen
e nce a n d aga i nst t h e ava i l able resea rch evidence
arios as the i r exp e r t i se deve l o p s . I f needed . l o n g e r
(Herbert e t al . . 2 0 0 1 ) : when d i fferences are id e n t i
l earn i n g sessions a re poss ible with clinical simula t i o n s .
fied . d o n o t s i mp l y assume you or they a re correct,
a
rather. exp l o r e t h e basis o f yo u r thou g h ts and
w i t h a rea l p a ti e n t . A l tern atively. i f time i s l i m i te d . or
situation that
may
be n e i t her ethical
or p r ac tic a l
d e ci s i o n s w i t h a n open m i n d to adj u s t i n g yo ur
i f the lear n i n g go a ls d i ctate. then j u s t a part o f the
p er s p e c ti v e .
p a t i e n t e n c o u n ter ( e . g . th e h i s tory) can b e used in the s i m u l a t i on . I n a d d i tio n . some fo rms o f s i m u l a t i o n
At t h e u n dergraduate leve l o f ed u c a t i o n . Ca r r et a l .
a Uow
( 2 00 0 ) h a ve
time a n d place o f their c h oos i ng. consistent w i th a d u l t
d e s c ri b e d
s m a l l group prob lem-ba sed
a
c l i n i c i a n s t o l e a r n a t the i r o w n
pace a n d a t
a
t uto rial a p p ro a c h to th e p r e l i m i n a ry l e a r n i n g of re a
l e a r n i ng p rin c i p les . I t s h ou l d b e recog n i ze d . h o wever.
son i n g ski l l s t h a t is co n d u cted over two t u to ri a l sess ions.
t h a t c l i n i c a l si m u l a t i o n s
The a c t i v i t i e s i nvol ved req u i re the s t uden ts
to d raw o n
t he i r l ay ( o r l i m i ted hea l t h profess i o n a l ) k nowledge and
to identi fy the i r l e a r n i n g n ee d s as t h ey w o rk
throu g h an u n fold i n g s i m p l e simu lated c ase . F o l lo w i n g an i ni ti a l tri gge r. u s u a l ly a
b ri e f v id e o c l i p o f a p atien t
fu ll y t h e d y na m ic s of
a
a re
u n a b le to a pprox i m a te
r e e i l pa tien t e n c o u n t e r.
nor the
u n pred ictab i l i ty a n d v a ri a b i l i ty i n heren t i n d ea l i n g
w i t h rea l p a t i e n ts . T h e case rep o r ts presented i n S e c t i o n
2
a tt e m p t to
s i m u l a te the n atu ral te mporal seq uence of a p a t i e n t
cl inic a l d a ta i n s t a ges.
rich i n c u e s . the students' l e a r ni n g is fa c i l i tated by a
encou n te r b y prov i d i n g real
tu t o r, whose primary role is to keep the l ear ning process
th u s a l lowing responses to the a ss o c i a te d c l i n ical rea
'on track' rather t h a n prov ide the a n swer s . T h e tutor
so n i n g questions to be b a s e d on l i m i t e d data. The j ud i
patient i n fo r m a ti o n as they ro le p l ay the patient d u r in g the interview a nd for p hysi c a l exa m i n a tion proced u res. At v a r i ous stages d u ri n g the p r ob lem - s o l vi n g process . the students u nder take tasks. which inc lude l i s t i ng cues a nd r e l a ted i n ferences, sum
c i o u s p l ac ement of re a so n i n g q u estions, inte rspersed
prog ressi vely proVid es
marizing the prob lem(s) and wh a t is known about i t .
generating hy potheses acc ompan i e d by suppor t i n g / negati ng e v i dence. ob t a i n i n g p a t i e n t i n formation ( i . e . d ata collection ) . d eve l o p in g lear n i n g goal s . and i d e n tify ing fu rther information (e.g. bioscience lm owled g e.
c1.in
ical assess m e n t ski l l s ) requ ired to solve the probl em(s) .
d e v elo p m en t of skills in c l i n pro b lem- based l e a r n i n g ac tiv i ty
As we ll as fos t er i n g th e ical r e a so n i n g , such a
( B a r rows a n d Ta m b l y n .
1 9 8 0)
Lear n i n g activities involv ing simu l a ted clinica l scen a dva n tag e s .
in the i n formation flow, is designed to stimulate the r ead e r ' s cogni tive processes . The sti mu lus questions a re open ended and , t h ere fo r e , re q u i re e x p l a n a t i o n , j ustifi c a ti o n a n d extra polation . The pro v ision of the expert cl i n i c i a n s ' respo nses to t h e q u es tions enables the clinician to compare their t h i nk in g w ith
t h a t o f t h e expert a n d o b t a i n immed iate feed back. An a w are n ess of c l i n ic a l reason i n g theory is also facilitated thro u g h the use o f the clinical re a so n i n g commentaries . w h i c h h i g h l ig h t the rea s o n i n g processes evident i n th e exper ts ' responses .
also e n c o u r a ges self
res p o n s i b ility in l e a rn i n g . arios offer m a ny
a m o n g s t the u n fo l d i n g c l i n ic a l fi n d i n gs but o fte n at n a tu r a l ' b real<s'
These include dimin
ethica l and safety ri sks c ompa red w i th l e a r n ing activi ties w i th re a l p a ti e n ts , a nd t h e oppor t u n i ty to ex plore a l te r n a tive eva l u ation a n d treatment deci sions in t h e a b se n c e of time con s t r a i n t s a n d poten t i a l nega tive e ffects o n the p a t i e n t . Clin i c i a n s can s a fely learn [rom their m i sta kes . cha n ge their mi n ds . explore options. c r i t i q u e a l ternative expl anations and ide n ti fy assumptions and biases in their t h inkin g . Furthermore, ished
simu l a ted case scenarios provide control over problem type. consis tency a nd c o m plex i t y, al low i n g the case
to
• F u rt h e r acti vities Cogn itive/ m i n d m aps An exc e l l e n t way
to fa ci l i ta t e t he exp l o r a t i o n o f
a
c li n
ic i a n ' s k now l e d ge base a nd reason i n g processes throu g h the use o f cognitive maps.
is
or mind maps (Cahill
and F o ntey n . 2000; Higgs. 1 9 9 2 ) . Mappin g external izes a c l in ic i a n ' s organ ization of knowledge on a g i ven topiC (e.g. a cU nical sy n dr o m e ) in a way that allows new know l e d g e to be ad ded . It is a g r a p h i c a l representa tion of asso c i a ted k n owledge. r e vea l i n g preconcep tions, a s s u m p tions, b i ases and scope o f percepti o n .
Copyrighted Material
In'
TH E O RY A N D D EV E LO P M E N T
Re l a t i o n s h i ps a n d con nectio n s be tween co ncepts and
a n d presenting it by the use of role p l aying an d over
ideas a re clarified by t h e mappi n g , and the formation
head tra nsparenCies . Following the prov ision of i n tro
o f new relationships and mea n i n gs is fa cil i tated by fos
d u ctory cues, su bseq uent case i n formation is o n ly
terin g of creative and djvergent thinking . It is , therefore,
released on request i n a piecemeal fa s h i o n . The sec
a powerful lear n ing tool that pr i m ar ily uses critic a l self
ond p a n e l of two or t hree participants are the nov ice
rellection to promote the development of metacogn i tive
c l i n ic i a n s , whose role it is to work through a n d solve
ski l l s a n d the pos itive reconstruction o f knowledge
the c l i n ica l problem . The fi n a l p a n e l consists of one or
n e tworks.
two expert manual therapis ts a n d possibly an expert
The process o f completing
a
cogni tive map com
1. B ra i n stor m i ng
an
d thinking o f anyth i n g to d o with
the topic i n q uestion
2.
G roupin g t he b r a i nstormed items
in a l og i c a l m a n n er, w i th con sideration give n to the rel ationships between ind ivid u a l i te m s
3 . Re l a t i n g the groupings of i tems to o n e another
show i ng the connections with l i nes or ar row s , accompa n ied b y
a
in a related fi e ld (e.g. ort hopaed ic s u rgery ) . T h eir ro le is to pose s t i m u l u s q ues tions to the novice cl i n ician
monly i nvo l ves three stages.
b r i e f description as t o h o w t hey
are related ( e . g . 'leads to' or ' is needed fo r ' ) .
panel i n order to c h a l le n ge their knowl edge a n d rea soning processes , i n addition to p r ovi d i n g feed back to the nov ice c l i n icians. T he reaso n i n g of the novice cl in ici a n s is ex p l ored v ia questi o n s s u ch as ' What i n for mation do you next need? ' , ' Why do you want to know
that?' a n d ' How do you i n terpre t these fi nd i ngs a nd how d o th ey re l a te to yo ur wo r k i n g hypo t h ese s ? . The '
chairperso n is i n overall control of the learnin g activity, guid ing the genera l direction of the discussion (includ ing promoting d iscussion o n the n a t u re of c l i nical
A ( pre-) cogni tive m a p may b e completed before a par
reasoni n g) and m a n a g i n g time. At the end o f the ses
tic u l a r rellective learning activ ity, a n d a n o ther (post-)
s i o n , feedback from peers in the a u d ience is e n cour
cogn itive map comple t ed aftenvards. Comp letin g the
a ged throu g h genera l d eb a te a b o u t the case.
map before the lear n i n g activity (e.g. lecture, continu
The ainls of the ' fish-bowl ' fo rmat are to increase the
i n g educa tion cou rse, etc ) a c tivates the individu a l ' s
novice cl i n ician's awareness o f the nature o f clinica l
existing know ledge on t h e topic, someth i n g recom
reaso n ing and their own reasoning processes ( i n c l u d
mended in experienti a l l e a r n in g (Kolb, 1 9 8 4 ) . Com
i n g the relevance a n d breadth of t h e ir own know
p l eti ng a second post- learning map serves as bo t h
ledge base) and to promote t he deve l o pme n t of skills in
a
review of the i n fo r m ati o n o b t a ined ( n o w h opefu l ly
metacognition and communication o r reason i ng
i ntegrated i n to the prior knowledge on the to pic) and a
et a I . ,
means of eval u ating what wa s learned and the learning
prompt the novice c l i n icia n s to eval u ate the val idity
(Carr 2 0 0 0 ) . Q uestions posed by the expert clinicians
activ i ty itse l f. If the learni n g ac tivity was successful .
of their knowledge and to review th e i r clinical reason
you wo uld expect to see si g n i fi ca n t c h a n ges ( e . g . more
i ng strategies critically, thus enhancing self-awareness
inter-re l a tionships o f greater complex i ty) in the post
and faciHtati n g rellec tion and metacogn iti o n . Novice
lea r n i n g cog n itive map.
c l i n icians are requ ired to express and critique their th oughts
Pan el d is c u s s i o n or 'fish- bow l ' gro u p s
verb ally,
i nclu din g
the
fo rmulation
of
hypotheses and provision o r j ust ifIc a ti on for requesti ng fu rther patient d a t a . F u r thermore, key prog ress find
S m a l l g r o u p lear n i n g activities a r e also fe asible for
i n gs c a n be with held until the l e ar ner has comm itted
classes in ma n u a l therapy a n d fo r manual therapy
to
profess ional groups. In particular, actual or hypothet
i n rormation th ey req u i re and why and deve l oped cri
ica l case reports c a n be ex p l ored in depth u s i n g a ' fi s h
2 0 0 0 ) . A n approach to this s tyle of learning has been
teria for r u l ing-in or r u l i ng-out hy p o t h eses (Scott, 2 000). T h is a p p roach acce lerates the acqu isition of the pa ttern-rich, situation-speciftc and readily recallable
descr i bed (Higgs, 1 9 9 0) as fo llows . PartiCipants are
heuristic knowledge typica I o f exper t clinicians ( Scott,
bowl' or panel discussion gro u p format (Carr et aI. ,
a
wo r ki n g hyp othesis, decided wh at additional
semjcircular arra nge
2 000) , that is c l inical patterns and assoc iated ' i f/then'
ment with three panels and the chai rperson . The fi rst
g U ides to a c t i o n . It a l s o i m pe ls n ovice cl i n icians to
sea ted before a n a udience i n
a
panel o f two or three participants represen ts the patient
assess a n d revise their knowledge base in terms of
and is respo nsible for preparing the case rep ort ( if neces
accuracy, comprehens iveness and org an i za ti o n ( Carr
sary, with the assis tance o f a more senior practitioner)
et al. .
Copyrighted Material
2 00 0 ) .
26 I M P ROV I N G C L I N I C A L REAS O N I N G I N M A N UA L T H E RAPY
web-based forums , includ ing e-mail lists, news groups,
Reth i n ki n g a patient p resentation
To foster skills in creative or lateral thinking. a clinician can choose a patient from t heir current list and attempt to re-approach the problem by t h inkin g l atera l ly using
electronic d iscussion g roups and real-time chat ses sions can facilitate the s h a rin g of c l i n i c a l experiences a nd exch a n g i n g of ideas.
the previously d i sc ussed strategies of re-examining the parts or re-analysing prev ious interpretations ( L e . look ing outside the approach
Conclusion
that is presently being taken) .
While the re-analysis o f prev ious i n terpretations c a n b e d o n e i n o n e sessio n . t h e c l i ni c i a n s h o u ld u s e their
C l i n ical re a s o n i n g u n d e r pin s all types o f m a n u a l
own d iscre t i o n as to how l o n g to fo l low t hro u g h w i th
therapy practice a n d is t h e fo u nd ation of clinical s u c
a ny cha nge in the tre a t m e n t i tse l r. A fter completing
c e s s . Expertise i n m a n u a l therapy
the exerc ise. a b r i e f (one page ) acc o u n t o f the results of the re-a na lysis and c h a n ge i n treatmen t c a n inclu d e a ny n e w i n s i g h t s or re-co n fi rmations of prev ious in ter
organized k n owledge clinical experi ence ,
requires highly structu res b u i l t on reflective
i n a d d i t i o n to advan ced cognitive awareness of c l i n ic a l rea
and metaco g n i ti ve s k i l l s . An
improvement i n the p a t i e n t ' s status from what was
son i n g processes , espec i a l ly expert decis i o n m a k i n g reaso n i n g errors, i s a l s o essen t i a l for the deve lop men t of cl inic a l ex p e r t ise. Clinici a n s w i s h i n g
prev iously be i n g achieved . rather i t i s an exercise in
to enha nce t h e i r c l i n i c a l reaso n i n g s k i l l a nd adva nce
p retatio n s . T h i s w i l l n o t necess a r i ly prod uce a ny new brea kth roughs in m a n u a l th era py. or even a defi n ite
a n d common
fac i l i tating looking outside one's own patterns. New
along the continuu m o f expertise need to adopt a d u l t
every
learning prinCiples a n d actively engage i n clinical prac
ideas and appro aches are not d iscovered in
attempt at latera l thinking. However. i f clin icians never
tice learning and pro fessional d eve lopmen t . Lear n i ng
re-exami ne their existing p a tterns or attempt some
u nder taken in
do emerge
the clinical c o n text with real patients
a ny ideas that
provides the optimal opporlunity [or progress. However,
will s i mply be variatio n s of existing ideas
there are also a variety of other activities that s i m u l a te
thing outside their usual approach. then rather than gen u i n e new approaches.
the cli n i c a l s i tuation and promote reason i n g profi c iency. Case reports, such as those in Section 2, provide a
E l ectro n i c m e d i a
particularly rich resou rce fo r improv i n g c l i ni c a l rea
soning . No ma tter which l e ar n i n g a c ti v i ties are used .
F i n a l ly. elec tronic med ia a n d communication h ave
collaborative i n teraction with a mentor or peer in
for ums in recent years where cli nicians c a n
this process is cruc i a l fo r build in g the extensive body
seek i n p u t and feed back from their i n ternational peers
of cli n i c a l ly rele v a n t and c l i n ically accessi ble propos
provided
o n patient problems or contri b u te their own thoughts
i tiona l . craft and personal kn owledge typical of expert
about cli n i c a l prob l em s raised by o t hers. Interactive
practitioners .
• Refe re n ces Adoc Services
Llc ( 2 0 0 2 ) . P hysiosphere.
Ava i l a b l e on l i ne: http://www. p hysiosp here . c o m B arrows.
H . S . a n d Tam blyn. R . M . ( 1 9 8 0 ) .
2 nd edn 0. H i g g s a n d M . Jones . eds . ) 1 5-2 2 . O x ford:
pp.
Bu tterwor t h - Heinem a n n . Boud. D. ( 1 9 8 8 ) . H o w t o h e l p stu d e n ts learn from experience.
Approach to lv!ed i c a l Ed ucati o n .
In The Med i c a l Teacher. 2 nd edn ( D.
68-7 3 .
Stu ttgart: Spri n ger.
Cox a nd C. Ewao . e d s . ) pp.
C. ( 1 9 8 7) . S teps to an Eco logy of M in d : Collected Essays i n
Edi nburgh: C h u rc h i l l LiV ingstone. Brookfiel d . S.D.
Bu tterworth -Heine ma n n . C a r r. J . . Jones.
Problem-Ba sed Lea r n i n g . A n
B a teson.
i n the Health Profess i o n s . 2nd edn 0. Higgs and M . Jones. eds . ) pp. 2 1 4-2 2 1 . Ox ford :
( 1 9 8 9 ) . Deve l o p i n g
M . a n d H i gg s . J . ( 2 000 ) .
Lea r n i n g reas o n i n g i n p hysiotherapy progra m s .
In Clin ical Rea soni n g i n
the H e a l th Profes s i o n s . 2 n d e d n 0. H i ggs and M . J o n e s , eds . )
1 9 8-2 0 4 . O x ford:
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Critica l Th i nkers. C h a l le n g i n g A d u l ts
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mind mapping t o improve s t u d e n ts '
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E rl b a u m. Hayes . B. and A d a m s . R . ( 2 0 0 0 ) . Parallels between c l i n i c a l r e as o n i n g a n d ca tego riz a t i o n . I n C l i n i c a l Reasoni n g i n the H e a l th P r o fess i o n s . 2 nd edn
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R e pr e s e n t a t i o n o f H u m a n J u d geme n t ( 8 . K l ei n m u n lz , ed . ) p p . 1 4 9 - 1 8 6 . C h i c hester, U K : Wi l e y.
( 1 9 8 4) . Experien t i a l Le a r n i n g : E x pe r i e n ce fi X the S o u r c e o f Lea r n i ng a n d Deve l o p m e n t . E n g lewood Cl i ffs . Nj: Prentice-Ha l l . Ladyshewsky, R . . Ba ker, R . a n d J o n e s , M. Kol b , D. A .
J o n e s . eds . )
p p . 4 5 - 5 3 . Oxford : B u tterwo r t h - H e i ne m a n n . Herb e r t .
C . M . . G w yer. J . . H ac k . L. IIII . a n d S h e p a rd , K. F. ( I LJ <) LJ ) . Exper l is e i n P h y s i c a l Ther,lpy P r a c t i c e . Oxford : B u tterwo r t h - H e i n e m a n n .
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B u t terworth-Hei ne m a n n . Jense n .
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R . D . . S h e r r i ng t o n . C . , M a her. C .
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b a s ed p r a c tice: i m pe r fe c t but
( 2 0 0 ( ) ) . Peer co a c h i n g to gen era te
necessary. P hy s i ot h er a py Theory a n d
c l i n i c a l-re as o n i n g sk i l l s . In C l i n ic a l R e a s o n i n g ill t h e Heal th P rofess i o n s , 2 nd edn (J. Hi ggs a n d M . J on e s . ed s . )
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1 7 . 2 01 -2 J l .
Higgs. j . ( 1 9 9 0 1 . foste ri n g t h e a c q u i s i t i o n
of c l i n i c a l rea s o n i n g skills. New Zea l ,m d j o u r n a l of P h ys i o t h e ra py. 1 8 ,
process
D e ve l o p i n g k n owl ed ge : a
of c o n s tr uc t ion , m a p p i n g a nd
Me d i c a l Ed u c a t i o n ,
6 3 8- 6 3 9 .
D . R . ( 2 ()OO ). and b i o m ed ic a l k n ow l e d g e : i m p l ic a t io n s fo r t e a c h i n g. In C l i n ic a l Reas o n i n g i n t h e Hea l t h Profess i o n s . 2 n d ed n ( J . H i ggs a n d M . J o nes, e d s . 1 pp. 3 3 -4 4 . Oxford: C l i n i c a l re ason i n g
B u l terwort h - H e i n e m a n n .
S . ( 2 0()() I . l ' h c c a se s t u d y a s <I n me t h od t o t ea c h c l i n i cal rea s o n i n g . In Cl i n i c a l Reason i n g i n t h e H e a l t h Profes s i o n s . 2 n d c u n
I'rio n .
instructional
(j. H i ggs a nd M . l on e s . ed s . 1
pp. 1 7 4- 1 8 .3 . Oxford : B u tterwor t h - H e i n e m a n n .
Rawso n .
M . ( 2 0 0 0 ) . Lea r n i n g t o l e a r n :
m ore t h eUl a s k i l l set. S t u d ies i o
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H ig h er Ed uc a t i o n , 2 5 ,
Re fs h a u gc,
Teac h i n g c l i n i c ,, 1 re a s o n i ng. I n
C l i n i ca l Reaso n i n g i n t b e Hea l t h Profess ions , 2 n d eu n (J . H iggs a n d M . jones. cds . ) p p . 1 4 1 - 1 4 7 . O x ford : Bu tte r w or th - I-l e i n em a n o . Rege h r. G . a n d N orm a n , C . ( l LJ 9 6) . Issues in cog n i t i ve ps yc h o l og y : i m pl ica t i ons
for profeSS i o n a l ed ucation . A c a d e m i c
9 8 8- \ 0 0 0 . ( 1 9 <) 9 ) . M a n u a l t herapy c u l t s . [ E d i toria l 1 Man ual Therapy, Med i c i ne , 7 1 .
Rivett. D. A .
4 , 1 2 5- 1 2 6 . R i vett, D. a n el H i g g s , j . ( I 9 9 5 ) . Exper i e nce and exper t i s e io c l i n i c a l rea s o n i n g .
New Zea l a n d jo u r n a l o f Physiotherapy,
2 3 . 1 6-2 1 . S.E . . R i c h a rdson ,
Sackett. D. L . . S t r u u s ,
WS. et
a l . ( 2 0 0 0 ) . E v i d e nce-Based
P r a c t is e a nd Teach 2 nd e d n . Edinbur g h : Ch u rc h i ll
M edic i n e : How to
Bu tterwo r t h -Heinem a n n .
EBM,
S i t u a ted Lea r n i n g . Ava i l a b l e o n l i ne
(2 August 2 0 0 2 ) :
Livings tone.
Schneiders , A . G .
and
R i ve t t . D. ( 2 0 0 0 ) .
Eva l u a ti o n of a co mputer assi sted
( CAL) progra m for c l i n i c a l
re v i ew. New Zea l a n d jou r n a l o f
h ttp: / / w ww.educaliona u . ed u . a u / fi re
lea r n i n g
P hys i o t h e r a py, 2 0 , 2 3 - 3 0 .
h ives/ cplO4k. htm
reaso n i n g in m a n ipu l a tive
H i ggs . j . a n d
B ithe l l . C . ( 2 0 0 1 ) .
M a i tl a n d ,
Professional expertise. [n Prac tice Kn o w l e d g e a n d Expertise in
tbe
H e a l t h Profess i o n s U . Higgs a nd A. Titche n , eds . ) pp. 5 9 - 6 8 . O x fo rd :
Bu tterwor th-Heinem a n n . H i g g s , j . and jo n e s , M . ( 2 0 0 0 ) . Cl i n ic a l
reason i n g i n the h e a l t h professio n s .
C .D. ( 1 9 9 9 ) . Ve r tebra l
Manipu lation : A Case Stud y in Low
13 ack
Pa i n . [Video] Oxford :
E u tterwo r th - H e i nem a n n .
Marti n , c . . S ibsteen. A . a n d Shepard . K . r. ( 1 9 9 9 ) . T h e profess i on a l deve l o p m e n t o f es pert
p hy s i c a l therapists i n fo u r
a reas o f c l i n i c a l practice. ln E x pertise
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p p . 2 8 3 -2 8 9 . O x ford : Lave, I . ( 1 9 9 6 ) . Lear n i n g Theories:
1 3- 1 7 . H i ggs. J . ( 1 9 9 2 ) .
i n Phy s i c a l Thera py P r a c t i ce ( C . M . J e n s e n . J. Gw yer. L . ivI . H a c k a n d K . F Shepard) p p . 2 3 1-244. Ox ford : Bu l l e n.vor t h-Hc i n e m a n n . Mec h a n i c . D . fi nd Parso n . W. ( 1 9 7 5 1 .
p hysi o t h e r a p y. In Procee d i ngs of
the
l n ternali o n a l l'edera t i o n o f O r thopaed ic a n d M a n i p u l a ti ve Thera p ists Conference
(K.P S i nger,
ed . ) pp. 3 9 5 - 3 9 9 . Per t h , A u s t ra l i a :
I n ter n a t i o n a l Federa tion of" O r t h o p a e d i c a n d M a n i p u l ative
T h e rap i s L5 .
2 6 I M P ROV I N G C L I N I C AL R EAS O N I N G IN M A N UAL TH ERAPY
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Action. Lo n d o n : Te m pl e S m i th . S c h o n . O. A . ( 1 9 8 7). Ed ucating the Reflective Practitioner. San Francisco. in
C A : Jossey-Bass.
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to med i c a l students. [n C l i n i c a l
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Thera p i s ts. 2 n d ed n . O x ford : B u tterwo r t h -Heinema n n .
Simon. H . A . ( 1 9 8 0 ) . Problem s o l v i n g and e d u c a t io n . In P r o b l e m Sol v i n g a n d Edu cation: Issues i n Teac h i n g and
and F. Re i f. eds.) pp. 8 1 -9 6. H i l lsda le. NJ: Erl b a u m . Research (O.T. Tu m a
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Titche n , A . ( 2 0 0 1 ) . Critical compan ionship: a conceptual framework for developin g expe rtise.
[n Practice Know ledge a n d Expertise i n the Health Professions 0. Higgs and
A. Titchen. ed s . ) pp. 8 0-9 0 . O x ford : B u t terwor th-Hei n e m a n n .
Wa tts. N.T. ( 1 9 9 5 ) . Tea ch i n g the components o f c l i n i c a l d e c i s i o n a n a lysis in the c l assroom and c l i n ic. [n Clinical Reaso n i n g in the Hea l t h Profess ions U. H i ggs a n d M. Jones. ed s . ) pp. 204-2 1 2 . Oxford: Butterwo r t h - Hei nema n n .
Refl ective d i ary
A n exa mple o f a reOective d i a r y o f c l i n i c a l p a t terns u sed t o fac ilit a te skills in p atte r n recognition b y record i n g t y p i c a l p a tte r n fe a t u res a n d c o m p a r i n g similar. competing patte r n s . This diary. from the U n i versity of S o u t h
Austra l i a . i s designed to fa c i litate t h i n k i n g about b i o medic a l fea tur e s o f nociceptive pattern s .
. C o m parative patterns
.
A re a : S o u rce
B e h avi o u r
P recau t i o n s/Con trai n d icat i o n s
H i story
Contributing factors
Physical exam i nat i o n
M a n age m e n t
A rea : S o u rce
420
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APPEN DIX
�. "
-
,..,
�.
S e l f- refl e ct i o n wo rks h e et
2
Sel f-reOection worksheets. s u c h as this CUnical Reasoning ReOection Form fro m the U n iversity of South Australi a . c a n be used to prompt and record the c l i n ic i an ' s t h i nk i n g processes.
� l i n i cal Reaso n i n g Refl ection Form NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE. . . . . . . . . . . . . . . . . . . . . . . .
PATIENT'S NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pe rc e p t i o n s/ i n t e r p re t at i o n s o n c o m p l e t i o n o f t h e s u b j e c t i v e e x a m i n at i o n
It is i mpor tant to recogn ize that the patient's presentation and factors affec ti n g i t (e.g. p hysical, environ mental . psy chosocial and health managemen t via p hysiotherapy or other me a ns) can be c h arac terized in pain la nguage/ mech anisms by the domin an t Input. Processing or Output pain mechanisms that appear to be affected . This should be considered when formin g j ud gments regarding the other hypothesis ca tegories. as interpretations o f t h e patient's symptoms. psychosocia l status a n d signs will vary with t h e dominance of p a i n mechan isms present.
1 I.I
Activity and partici pation capab i l iti es/restri cti o n s Identify t h e key abilities and restrictions the p atient has in exec uting activities.
Abil ities:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Res tric tion s : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2
.
Ide n ti fy the key abil ities and restric tions the patient has with involvement in life situations ( work. fami ly.
sport. leisure ) . Abil ities :
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Restrictions: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
.
Patient's pers pectives on t h e i r experi e n c e
Identify t h e patien t ' s perspectives (posi tive a n d negative) on t h e ir experience ( e . g . cognitive - patient understa nding. beliefs , attributions . and affective - patient feelings/emotions r e g a r d i n g the problem and its management
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421
APPE N D I X 2: S E L F · R E F L E C T I O N WO R K S H E ET
3
Path o b i o l ogi cal m e c h an i s m s
3.1
Tissue mechanisms
A t what stage of the i n flammatory/hea l i n g process would you j u d ge the principal d isorder to be ( e . g . acute i n flammatory phase 0- 7 2 h . proliferation phase 72 h to 6 weeks, remode l l i n g a n d maturation phase
6
weeks-several months) ?
If the disorder is past the remodellin g and maturation phase, what do you think m ay be m a i n t a i n i n g the sy mp toms/ activ i ty-participation restrictio ns? (e.g. unhelpfu l perspectives/psychosocial factors, physicallbiomechan ical i mpa irment, systemic dise ase. env ironmentallergonomic factor s . behavioural factor s , central processing factors, etc . ) ?
3.2 3 .2. 1
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Pain mechanisms List the subj ective evidence which supports each specific mechanism of symptoms. Re member that aU
mechanisms are operating i n every presentation but i n d ifferent way s . The key is to identi fy the d o minant mec h anism and po tential risk factors for normal mechanism i nvolvement to become pathological ( i . e . counter prod uctive to recovery) :
I n pu t Mechanisms
Processing Mechanisms
Output Mechanisms
N ociceptive
Pe l'iphe l'al evoked
C e ntl'ally evoked
Patien t's p e l'spectives
Motol' and
sympto ms
n e u l'ogenic
n e u l'oge n i c
(cognitive/affective
auto n o m i c
sym pto ms
symptoms
i n fl ue nces)
mechanisms
3.2.1
Draw a 'pie chart' on the d i a gram below that reflects the proportional i nvolvemen t of the pain mech
anisms apparent a fter comp letin g the subjective examin atio n .
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A P P E N D I X 2: S E LF- R E FLECTI O N WO RKSH EET
lfi'
Iden tify any potential risk factors (e.g. yell ow, blue a n d black flags) for normal mecha nism involvement to become ma l adaptive (Le. cou n terprod uctive to recovery) :
3.3
3 .4 From yo ur subjective exami n ation , identi fy a ny features in the pati ent's prese ntation tha t may rellect impa irment i n the neu roendocri ne and neuroimmune systems: Neu roendocrine: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . ,
Neuroimrhune: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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The so u rce(s) of t h e sym pto ms
4.1
List i n order or likeli hood all possi ble structures at fault for each area/component o f symptoms.
Source
Area 1 :
Area 2:
Area 1:
Area 4:
Somatic local Somatic referred N e u roge n i c (peripheral a n d/or cen tral) Vasc u l a r Viscera l
H i gh l ight w i t h * those structures w h i c h m u s t b e exa m i n e d
DAY 1
Do the symptoms appear to fit those . commonly associated with a particular physical syndrome/ d isorder / pathology?
4.2
If not, does th is suggest the need to ex amine other factors (e.g. yellow flags , sinister pathology ) ?
5 5.1
Contri b u t i n g fact o rs
Are there any contributing factors associa ted with the patient's symptoms? Specify: (e.g. biomechanical, muscle length/strength/con trol , j oint mobility, neural mobility, posture, etc. ) .
Physical
Environmenta l / ergonomic
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(e.g. patien t ' s perspectives/u nderstanding of problem and requ i rements for recovery/man agement, feelings regard i n g problem a nd its manage ment, attributions. health beliefs . etc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychosocial
. .
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If!! 6 6.1
A P P E N D I X 2 : S E L F - R E F L E CT I O N WO R K S H EET
The behav i o u r of the sym pto m s G ive you r i n terpretation for e a c h o f the fo l lowi n g :
Severity high
low Irri t a b i lity symptom 1 ------
no n-ir ri table Irrita b i l i ty symptom
2
------ 1
very irritable
---
no n-irritable
---- 1
very i r ri tabl e
G ive exa mple of irritab i l i ty : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What are the im plications o f t h i s answer to your physical ex a m i n a ti o n ? (see
8 . 3 . 8 . 4)
Rel a tionship o f patie n t ' s activity/p articipation restrictions a nd/or symptoms to each other Behavioural (e. g . can symptoms occur a l o n e o r are they l i n ked via agg ravati ng and e a s i n g fac tors) . . . . . . . . . . . . . . . .
.
Historica l ( e . g . wh at is the relationship of the symptoms over time--biome ch a n i c a l ly. motor contro l . patho-
p hys i o l o g i c a l processes?)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Precautionary q u e stions ( e . g . general he a lth . red n a g s ( e . g . s p i n a l co rd. vertebroba s i l a r i n s u ffiC iency. c a u d a
e qu i n a . we ight loss) . med ic a tio n s . i nvestigatio n s . ye llow n a g s and psyc h osoc i a l facto r s . e tc . ) . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2
. .
G ive you r i n terpretation o f the contri b u tion of mechanical and/or i n ll a m matory fe atu res to t h e n o c i cep足
tive component.
1
I n n a m matory
------
o M ec h a n ic a l
------ 1
10
1
1
o
10
List those factors t h a t s u pport your decision . Fac t o r
S u p porti n g evi d e n ce
I nfl a m m atory
Mechanical
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A PP E N D I X 2: S E LF- R E F L E CT I O N WO R K S H EET
What are the implications of this an swer to your p hysical ex a mination? (see
7
8 . 3 . 8 . 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
H i story of the sym ptoms
7. 1
Give your in terpretation
N a t u re
of the h istory ( p rese n t a n d past) fo r each o f the fo l l o w i n g : of the o n s e t ( e . g . i s i t consistent with a particu l ar s y n d rome or su ggest a d o m i n a nt p a i n mec h-
anism ? ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extent of i mp a i r m e n t a n d
a ssocia ted
dence ) . Also d oes this fi t w i t h
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tissue d a m age/change (e.g. mild versus severe a n d supporting evi-
predom i n a n tly perip hera l ly evoked o r ce n tral ly med iated process ? . . . . . . . . . . . . . .
a
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What a re the i mpl ications for t h e physica l exa mination ( s pecifi c a l ly. how do yo u r p r i o r i ties c h a n ge for day 1 phys ica l e x a m i n a ti o n ) ?
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Progression since onset (includ i n g stage a n d rate
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o f imp a i rment a n d stabil i ty of the d i s order) . . . . . . . . . . . . . . . . . . .
Are the patie n t ' s symptoms consiste n t with the history ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Exp l a i n if not. why not: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
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Precau t i o n s and contrai n d i c ati o n s to phys i cal exam i n at i o n and manage m e n t
8.1
Docs t h e s u bjective exami nation i n d i c a te c a u tion
(e. g . highly irrita b l e c o n d i ti o n , rapi d ly wo rse n i n g . pro足
gressive neu rologic a l ly, genera l h e a l t h , potenti a l vertebro b a s il a r o r s p i n a l cord impairment. we ight loss, medications. i nves t i ga t i o n s , etc. ) . Ex p l a in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.2
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Do the symptoms i n d icate the need for spec i fic tes t i n g as a day 1 priority ( e . g . instab i l i ty tests , peri phera l neu rologic a l , vertebral artery tes ts, fu rther medical i nvestigati o n s , etc. ) ?
or cen tral nervous system Exp l a i n
8.3
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At which p O i n ts under the fol lowing headings w i l l you l i m i t yo ur physical exa m i n a t i o n ? C i rcle the rele足
vant descriptio n . Local sym pto m s
Referred sym ptoms
(consider each
(consid e r each
verte brobas i lar
c o m p o n e nt)
c o m p o n e n t)
i n s uffi c i e n cy
Short of P1
Dysth esias
Sym pto m s of
Visceral symptoms
Short of prod uction
Po i n t of onset!
Po i n t of onset!
Point of onset!
Poi n t of onset/
Po int of ons et/
increase in resting
i n c rease in resting
i n c rease i n resti ng
i n c rease in resting
i n c rease i n resting
sympto m s
symptoms
symptoms
sy m ptoms
sym pto m s
Partial re p ro d u ction
Pa rtial reproduction
Partial reproduction
Pa rtial reproduction
Pa rtial re p rod uction
Total reproduction
Tota l re production
Tota l repro d u ction
Copyrighted Material
Total re prod u ction
't.1L-A p PfN D 'X 2 : SfL F- R fFLEC T' O N WO R K SH EET .. ' __________________ __ _____ __
__
ďż˝(
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Consideri n g yo ur a n swers to Question 8 . 1 , a nd in addition to your a n swer to Question 8 . 3 . at which point
8.4
wi l l you l i m it the exte n t o f yo ur p hysic a l exami n a t i o n ? Tick the re leva n t descript i o n . Active exam i nation
Passive exam i n at i o n
Active move m e n t s h o r t of l i m i t
Pass i ve movement s h o r t o f R 1
Active l i m i t
Pass i ve m ove m e n t i n to m o d e rate res i s ta n c e
Active l i m i t p l u s ove r p res s u re
Passive move m e n t to fu l l ove r- p res s u re
A d d i t i o n a l tests
If the d o m i n a nce of the prese ntation w i t h t h i s patie n t is hypothes ised to be centra l as opposed to peripherally evoke d , provide an exa mple of how you will attend to this in this particular patient's p hys ical ex a m i n ation . . . . . . . . . .
What wo u l d your priorities b e for day 1 ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Is
8.5 Why ?
a
peri p hera l o r central nervo u s system neurologic al examin ation necessary?
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Is it a day 1 priority ? 8.6
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I f releva n t . d o yo u expect a compa rable sign(s) t o b e easy/hard t o fi n d ?
Ex p l a i n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.7
What are the clues
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(if a ny ) i n the subjective exam i n ation to m a n ageme n t and spec i fi c treatment tech-
n iq u e s that may be used ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Pe rc e p t i o n s , i n t e r p re t at i o n s , i m p l i c at i o n s fo l l ow i n g t h e p h y s i c a l e x a m i n a t i o n a n d fi r s t t r e at m e n t
9 9.1
C o n ce pt o f the pat i e nt's i l l n ess/pa i n experience W h a t i s y o u r assessment of the p a tie n t ' s understanding o f h i s / h e r problem ( Have y o u asked the
patient? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.2
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What is your assessmen t of the patien t ' s fee l ings ab o u t h i s/her prob l e m , i ts a ffect on h i s / h e r l i fe and how
i t has been man aged to date ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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APPE N D I X 2: S E L F - R E F LECT I O N WO RKS H E ET
9.3
What does the patient expect/want from you /your management ( L e . p atient's go als) ?
,a!
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Are the patient's goals ap propriate? Ex plain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Have you a n d the patient been able to agree on modified go a l s ? Expl a i n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.4
What effect d o you anticipate the patien t ' s u n derstandi n g and feelings regarding his/ her problem may
h ave on your m a nagement or the prog n osis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
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P hysical i m pa i r m e n ts
Identify the key physica l impairments from the p hysica l examination that may requ ire m a nagement! re-assessmen t ( e . g . posture. movement patter n s / motor contro l . soft tissue/mu scle /jointlneural mobility/sensi足
tivity. etc. ) .
1 ................................. . . . . . . . . . .................................................................................................................. 2................................. 3..............................
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etc.
Sou rces and path o b i o l ogi cal mechan i s m s of the patie nt's sym pto m s
11 1 1.1
List t h e components of symptoms a n d pathobiological mech a n i s m s identified i n Section 4.0 a n d 3 . 0
and number in order of likelihood the possible structure(s) at fault for each apparent component.
Then identify su pporting and negating evidence from the physical examination for each structure and pathobio!ogica ! mechanism
Component
Po ssible structure(s)
Physical exam i n ation
P hysi cal exam i n ation
at fau l t
supporting ev i d e n c e
n egati n g evi d e n c e
Copyrighted Material
APP E N D I X 2: S E L F - R E F L E CT I O N WO RKS H E ET
S u p porting ev idence
Pai n m e c h a n i s m s
N egati n g ev i d ence
I n p u t mechanisms: Nociceptive • Peripherally evoked neurogenic •
Processing mechanisms: Centrally evoked neu rogenic • Cogn itive and affective •
Output mechan isms: M otor • Autonomic
•
S u p porti n g evi d e n c e
T i s s u e mechan isms
N egati n g ev idence
Acute inflam matory phase Prol iferation phase Remodel l i ng and matu ration phase
1 1 .2
I n dicate you r p r i nc i p a l hy p o thesis regard i n g the primary sy ndrome / d i sord er and the d o m i n a n t patho-
b i o l ogical mech a n i s m ( s )
1 1 .3
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Tissue mec h a n i s ms-he a l i n g mec h a n isms
D o your fi n d i ng s o n physica l examination ch a n ge your i n terpretation related to Q uestio n 3 . 1 rega rd ing the stage o f the i n fl a mmatory / h e a l i n g process? Exp l a in
1 1 .4
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Based o n yo ur u n dersta n d i n g o f the n a ture o f the d isorder ( e . g . i nflammatory deg ree o f irritabil i ty ,
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wor sen i n g . rate of i mpa i rm e n t and other indicators of the need for c a u tion ) . the pathobio logic a l mecha nisms .
operati n g . the patient's perceptions ( i . e . cogn itive/ a ffect ive status) and possible contr i b u t i ng factors. list the favoura b l e and u n favo urab le prognostic i ndicators :
Favoura b l e
U nfavo u rabl e
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APP E N D I X 2: S E L F - R E F L E C T I O N WO R KS H E ET
IU'
I m p l i c at i o n s o f p e rc e p t i o n s a n d i n t e r p re t at i o n s o n o n g o i n g m a n ag e m e n t
12 12.1
Manage m e n t
Do the phy sic al signs fit w i t h the symptoms? I f n o t how mig h t t h i s influence yo u r m a n agement a n d .
treatme n t prog n o s i s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1 2 .2 Is t h e r e a nyth i n g a bou t your p hysic a l e x a m i n a t i o n fi n d i n g s which wou ld ind icate the need for c a u t ion in yo u r m a n a ge m e n t ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E xp l a i n .
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12.3
D oes your i n terpreta tion o f the p hysic a l examin a t i o n c h a n ge the emp h a s i s of tre a t men t a s o u t l i n e d ?
1 2 .4
W h a t was yo u r management on
i nve stiga tions. etc. ) ? Why was t h i s c h os e n
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d ay 1 ( e . g . advice. exercise, passive mobilisation , referral for fu rther
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over the other o p tio n s ?
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If p a s sive trea tmen t w a s used , what was y o u r principle t rea tm e n t tech n i q ue ( s ) ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What physical ex a m i n ation fi n d i n g s support you r choice? ( In c l u d e
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i n your a ns we r a moveme n t d i a g ram of t h e
m o s t c o mparabl e passive s i g n ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Movement d iagram
12.5
What
I f you used a n active o r passive treatment o r advice o n d ay 1 , what wa s its e ffect? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
is your expectation of the pa tie n t s res ponse over the next 2 4 hours? '
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I
1 2.6
A P P E N D I X 2: S E L F - R E F L E CT I O N WO R K S H EET
Wh a t is yo u r p l a n a n d j u s tification of ma n a gement for this patie n t ( r a te o f prog ress i o n : address i n g
o t h e r problems/comp o n e n ts ) ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12.7
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Do you envisage a n eed to r e fer the p a ti e n t to a n other health provider ( e . g . physici a n . orth o paedic sur颅
geo n . neurologist/ neurosurgeo n . vascu lar surgeo n . e n d oc r i n ologist. psychologist/psyc h i a trist. a n aesthetist. d ietic i an . feldenkrais practition er. etc . )
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R e fl e c t i o n o n s o u rc e ( s ) , c o n t r i b u t i n g fa c t o r s ( s ) a n d p r o g n o s i s 13 13.1
Afte r t h i rd v i s i t H o w has yo u r u nders t a n d i n g o f t h e patie n t ' s problem c h a n ged from y o u r interpretations m ade fo l low-
ing the fi rst session? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
How h a s the p a tient's perceptions of his/her problem and m a n agement cha nged since the first sess i o n ? . . . . . . . . . . Are the patien t ' s n eeds being met? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 3 .2
.
.
O n reflection. what clues (if any) c a n you now recognize that you i n itially missed. misin terprete d ,
u n der- o r overwe i g h te d ?
What wou ld you do d i fferen tly n e x t time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14 1 4. 1
..
Afte r sixth visit H o w has y o u r u ndersta n d i n g of the p a tient's prob lem c h a n ged from y o u r i nterpre tations m a d e fol low-
ing the t h i rd sessi o n ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .
How has the patie n t ' s perceptions o f his/her problem a n d m a n a gement c h a n ged since the third sess ion ?
1 4. 2
On reflection, what clues ( i f a ny) c a n you now recog nize t h a t you i n i t i a l ly missed , m i s i nterpreted.
u n der- o r over-we i ghted? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What would you do d i ffe ren tly next time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 4.3 why ?
15 1 5.1
.
. .
I f the o u tcome i s t o b e s h or t of 1 0 0 % ( ' cu red' ) . a t wh a t p o i n t w i ll you cease m a n ageme n t and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
After d isc harge How has your un derstand i n g of the patient's prob lem changed fro m yo u r in terpretations made fo llow-
ing the s ixth sessio n ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :
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APPE N D I X 2: S E L F - R E F LECTI O N WO RKS H E ET
How has the patie n t ' s perceptions of his/her problem and m a n agement c h a nged s i n ce the six th sessi o n ?
I S.2
In hindsi g h t . w h a t were
symptoms?
the principal source ( s ) and pathobiolog i c a l mechan isms o f the patient's
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Iden t i fy the key su bj ective a n d phys i c a l fe atu res ( i . e . c l i n ic a l pa ttern) that e n tation i n
the fu ture.
Su bjective
P hys ical
Copyrighted Material
would help you to recognize this pres足
I n d ex
Page n u m bers in
bold i nd i c a te fi gu res a n d tables p bysical e x a mi n a t i o n . 1 2 5- 1 2 6
A
di s c u s s ion
ami commentary.
1 2 6-1 2 7 A bdom ina l muscle test i n g . movement impa i rment s y n d romes. 2 6 5 . 2 6 8 Abdomi n a l and pel v i c muscle fu nction s h o u lder pain. b i l atera l . l o n gd i s ta nce swimmer. 1 7 1 . 1 7 2
1 71
Abdom i n a l / twisties b a r. 1 70 .
headache. p hysica l exa m i n atio n . 1 3 8 low back. leg a n d thorax tro u b l es .
with ten n i s elbow a n d hea dache.
reassessment a n d fu rther treatment. 1 2 9- 1 3 0
glides. 2 2 2 Oexion and extensio n . 2 2 1 -2 2 2 . 2 2 2
discussion a nd commentary. 1 3 0 subjective examin ation . 1 2 3- 1 2 4
rotation. 2 2 1 .
discussion and commenta ry.
dysfu n ction fol l o w i n g car
1 2 4- 1 2 5
acciden t chronic post-inO amma tory fibro s i s .
An tero i n ferior synovial membrane pal patio n .
non-musc u l oskeleta l d i s order appearing a s m u scu l os keletal
TMJ. 246. 2 4 7
A n teroposterior gl ides
225 extensio n . 2 2 0 . 2 2 1 Oex i o n . 2 2 0 .
peripa rtum pelvic pain . chro n ic. 3 2 9 shou l d er p a in. b i l atera l . long-d istance
TMJ. 2 4 7
A n ti-in O a mm atory medica tion ankle spra i n . 1 2 4
mob i l ization i n to . 2 2 5- 2 2 6 ro t a ti o n .
motor ve h icle accident. 2 1 7 .
TMJ. 2 4 8 Activi ties o f d a i ly livi n g . 1 0-box scale.
22 1 . 2 2 2
rotation and Oexion. 2 2 2 Au tono mic nervou s system d is t u r b a nce fractured radius w i t b meta l fi xatio n .
craniovertebra l dysfu n c tion fo l l ow i n g
s w i mmer. 1 6 6
2 2 1 . 224
exercise. 2 2 6
exa m i n a t i o n . 1 3 8 . 1 44 Anteros uperior synovial membrane p a l pation .
disorder. 3 5 5
223
A tl a n to-occi p i t a l j oi n t . cra n i overtebral
cervical spine. headache p hysica l
42
229. 230. 2 3 3 . 2 3 7 pain state s . 1 6
224 med i a l c o l lateral l i gament i nj ury. 1 8 0 .
307 Activ i ty a n d p a r ti c i p ation capab i l ities/ restrictio n s . 1 3- 1 4 . 1
fun c tion fo l lowing car accident a n teriosuperior and antetioi n ferior
A n ky l o s i n g spondy l i t i s . 5 7 . 5 8- 5 9
Active movements
A tl a n to - a x i a l j o i nt. craniovertebra l dys足
S. 6 6
fe a r avoida nce a n d physica l i n c a pac i ty. u n necessary. 6 7- 6 8 m a l ad aptive centra l ized p a i n . 7 9 peri p a r t u m pelvic pa i n . c hro n ic. 3 3 4 thoracic p a i n limiling activity. 1 5 0 . 1 5 1 A d u l t ed ucator. role. 3 8 4 A d u l t learn i n g . 3 8 9-3 9 1 Aerobic exercise. 2 9 7 equ ipme n t . med i c a l exerc ise therapy. 290 A ffective d i mensions. activity a n d participation restriction s . 1 5
181 An t i c o a g u l ation therapy. contra i n d i c a t i n g
B
m a n i pu l atio n . 3 5 9 A n t idepress a n t s . 3 4 7 A n x iety
Back a n d bil a teral leg p a i n . 2 7-3 5 m a n a gement.
inj ury-rel ate d . pro[ess i o n a l sports pe rsons. 1 8 1 - 1 8 2 . 1 8 3 . 2 0 3 peripartum pelvic p a i n . chro n i c . 3 3 1 Ar throkinematic fu nction . thoracic p a i n l imi ting activity. 1 5 2 Ar throkinetic fu nctio n . thoracic p a i n l i mi t i n g activity. 1 5 2 - 1 5 3
Artic u l ar rest position retra i n ing. TMJ disc subluxa tion . 2 5 4
32. 33
discussion a n d commen tary. 3 2-3 3 . 34 o u tcome. 3 5 p hys i c a l exa m i n a t i o n . 2 9 -3 0 d iscuss i o n a n d commen tary. 3 1 subjective exami n a tion. 2 7-2 R discussio n a nd commenta ry. 2 8- 2 9 Backwards reason in g . 4 0 5
1 85
Age n ts for c b a n ge . becom i n g. 3 8 6
Assessment a n d learning. 3 9 3
B a l a nce board exerc ises. 1 8 4 .
A l ignment tes t. m ovem e n t i m pair m e n t
A thletes
B a l a nce machine. target tra i n i n g . 1 8 6
syndromes. 2 6 4 . 2 6 7
Ankle sprain in 1 4-year-old girl . 1 2 3- 1 3 4 m a n ageme n t . i n i tial. 1 2 7 d iscussion a n d com menta ry.
a d o lescen t hip p a i n . 2 6 1 -2 74
B a l l b o u nc ing exerc ises. 1 8 4
med i al c o l l a teral l i gamen t repa ir.
B asel i n e s . pacing a n d i ncrementi n g .
professional ice hockey player. 1 8 0-1 9 3
1 2 8-1 2 9
patell ofemoral p a i n . pro[es s iona l
o u tcome. 1 3 0- 1 3 3
te n n i s pl ayer. 1 9 4-- 2 0 4
discussion a n d commenta ry. 1 3 3-1 3 4
s h o u l d e r p a i n . bilatera l . l o ng-distance swi mmer. 1 6 1 - 1 7 9
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centra l ized p a i n m a n ageme n t . 8 1 B a teson. l e ar n i n g to learn. 3 9 4 B a ttersby. o n go i n g wor k p lace l e a r n i n g . 394 Behavioural s i g n s . Wa ddell. 7 5 - 7 6 . 7 7 . 34S
4JJ
""
I N DEX
, ,
B eh av i ou ra l t hera py medical exercise
Boud a n d Walker. experience-based
forearm p a i n p r even t i n g leis ure activities . 3 6 1
l e a r n i n g mode l . 3 9 1 - 3 9 2
the ra py 2 9 6
Be i n g t a u g h t . phenome n o n o f. 3 8 1 Bel ief syste m s , patie n ts , 2 8 7
Brachial Plexus Provocation Tes t ( B P PT) ,
B i a s i n pattern recog nition. 1 6 9
B re a t h i n g . pain on. tb o ra c ic p a i n fol l o w i n g car accident. 1 4 9 , 1 5 1 B r e a t h in g p a t te rn headache. pati e n t w i th history of
'
Bi cyc l e ergometer low back p a i n with scia tica . 3 0 7 med i a l co l i ateral l i game n t repa ir. pro fe s si o n a l ice hockey p layer. 1 8 4 . 1 8 4- 1 8 5 . 1 8 9 . 1 9 0
1 3 8 . 1 40
a s t hm a . 1 4 0
l o w b a c k a n d coccyge a l pa i n , ch ro n i c.
.
patel ioremoral knee inj u ry. profess i o n a l t e n n i s p l aye r 2 0 3 B i g picture approac h . 3 7 4 Biofeedback EMG , m u scle retra i n i n g . s ter n o 足 cleidomastoid and a n te rior s c a l e n e . 1 4 3 . 144 tra n s versus a bd o m i n i s con tractio n . 116 upper cervica l fl exi o n ac tion retra i n i n g . 1 4 3 . 144
406
B io medi c a l t h e o r y. ext r a po l a t i o n o f.
.
225
Biopsyc hosocial a p p ro ac h 1 7 . 6 6 . 2 8 0 l o n g st a n d i n g probl e m s . 6 2 peri p a r t u m p e l v i c p a i n , c h ro n i c . 3 2 8 . B i t i n g par a ru nc ti o n al h a bits. 2 4 3 . 2 4 4 B l a c k fl ag s . 8 . 1 9 , 4 2 Bladder urgency. chro n i c low back p a i n .
8 . 1 9 . 42
185
,
Body c b ar t a n k le s pr a i n 1 24 c r a n i overtebra I dy s fu nct i o n fol l o wing car accid e n t. 2 1 5 fac ial p a i n . chronic. 243 fea r avoidance a n d physical i n c a p aci ty, u n necessa ry. 6 1 .
67
fore arm p a i n preventing l e i s ure
.
l o w back a nd leg p a i n su bacute. 206 l e g a nd thorax troubles w i th tennis elbow and h eadac he . 37 pa i n , acute o n c h ronic. 340 p a in . c h r on ic . 5 2 . 6 0 pa i n a n d sc i a t ic a medical exercise the r a py reg i m e n . 2 7 6 me c h a n i c s e l bow. 8 8 non- muscu loskel eta l d i s ord er appearing as musculoskeleta l
,
'
shou lder p a i n . b i latera l . long-d istance swi mmer, 1 6 1 Body-mind c o n n ecti o n , fol low i n g c h ronic pa i n . 1 5 9 Bone po s i t i o n i n g a b n o r m a l . ten n i s elbow.
,
le a r n i ng . 4 1 4
C a u d a e q u i n a s yn d r o me. 5 3 Causal gic-type p a i n p a tter n . 1 2 4 Cen tra l mecha n is m s . p a i n . 1 5 . 1 6 . 1 7 . 1 8 . 46 u nnecessary. 6 9 . 7 7
forearm p a i n preve n t i n g l e i s u re activities. 3 5 9 .
3 6 6 . 3 6 7- 3 6 8 .
230
.
80
.
Chronic pa i n sta te. 1 0 4 see also Cen tral m ec h a n i s m s . p a i n C l i n i c a l e d u c a tio n a ffective and c og n i tive l earn i n g 3 9 2 goa l s of. 3 9 6- 3 9 7 C l i n i ca l fea t u res. paUero recogn ition see P a tter n recog nition C l i n i c a l fi n d i ngs. d i fferent i n terp r e ta t i ons
,
for. 3 6 9
C l i n ic a l i n t u i tion . 3 1 4 . 3 5 6 . 4 0 6--4 0 7 C l i n i c a l prac tice, 4 1 2--4 1 5 C l i n i c a l re as o ning activi ties to improve . 4 1 0--4 1 2 . 4 1 2--4 1 3 defi ni t i o n , 3--4
groin p a i n . elderly wo m a n 3 2 5 low back a c u te on c hro n ic. 3 4 3 and coccygeal pain. chronic. 1 04 . 1 1 0 leg a n d tho ra x tro u b l es w i th t e n n i s elbow a nd h e a dache, 3 7 . 3 8 peri pa r tu m pe lv i c p a i n . chro n i c . 3 3 2-3 3 3 49
.
thorac ic p a i n l i m i tin g activi ty. 1 5 5 trauma . p a t h o b i o l ogical c h a n ges 2 3 3 Ce n tral iza ti on o f pain . low back an d leg. 2 0 8 . 2 08-2 0 9 . 2 1 0 . 2 1 0-2 1 1 , 2 1 3
Ce r vical cause o r headache. 1 3 6- 1 3 7 . 146. 2 1 6
Cervic a l d i sc lesion con traind i c a t ing m a n ip u l a tion . 3 5 9
n o n - m u scu loskeletal d isorder appearing as musculoskeletal Cerv i c a l spine. 3 74
cord com pression , groin p a i n . e l d e rly wom a n , 3 2 4 . 3 2 5 i n cran ioverteb r a l dysfu nction
fo l l o w i n g motor v e h ic l e acc i d e n t .
muscle sta bil ization, 2 2 8 u p p e r j o i n ts. 2 2 0-2 2 2 degenerative c h a n ges. 2 2 0
fac ia l p a i n . c hron ic. 2 4 5 n ex i o n . c o n tra i n d ic a tio n s to. 3 6 3
Copyrighted Material
Centra l m ec ha n i sm s . p a in Chronic p a i n . co m mo n c o n sequ ences
.
C a s e reports . i nd e p e nde n t o r gro u p
2 1 6 . 2 1 8-2 1 9
Bou d a d u l t l ea r n in g . 3 9 0 work-based l e a r n in g 3 9 5 B o u d and Pascoe. e x pe r ientia l le a r n i ng . 391
C a p ab i l i t y ap proa c h . l earn i n g . 3 8 7 Cardiovasc u l a r work i n j ury- relate d a n x iety a l le v i a tion . prores s i o n a l sports pe r s o ns. 1 8 3 ,
d i sord er. 3 5 4 , 3 5 6
disorder, 3 5 2
i n s t ab i l i ty tests for u ppe r 2 4 5 mec h a n ic ' s elbow range of motio n . 9 1 source o f a r m pain. 8 7 . 8 9 . 9 2 . 9 5 Cervicolhoracic a n d u p per t h o racic
a n ky losi n g spondy l i t i s , S 5-5 6 . 5 7
p hysica l i m pairments, importance o r.
a c t iv i ties . 3 6 0
.
Chronic hy per se n si ti v i ty syndrome see
fractu red rad ius w i th meta l fLXatio n ,
B o d y blade exercises. 1 8 4 .
99
c
3 6 8 , 3 69 . 3 7 5
52. 53
.
i n c l usion in treatment. 2 4 0
spine extension, res isted . 2 2 6-2 2 7
rear avo i d a n ce and physic a l d i sab i l i ty,
334
.
rractu red rad i u s w i t h meta l fixa t i on
C h a n g e . promoting. 6 - 7 . 8 Chest exp a n s io n measurement.
1 84 . 1 8 9 . 2 0 3
B i omedical k n ow l edge.
B l u e fl a g s ,
1 0 5 , 1 0 5- 1 0 7 . 1 1 2 . 1 1 7
C 7 nerve root syn drom e . 3 6 6 m ob i l i t y te s t i n g 3 64
Cl i n i c a l re a s o n i ng errors. 4 0 6--40 7
commo n . 408 . 409 C l i n i c a l s i m u l a ti o n s . 4 1 4
C l i n i ca l /l'ie l d worl< educ ation , 3 9 6- 3 9 7 Coccygectomy. l o w back a n d c occ ygeal p a i n . chro n ic. 1 0 2 . 1 0 4 ,
111
C oc h r a ne Co l l aboration Back Review G ro u p . 2 9 7-2 9 8 Cogn i t i o n . 7
C og n i t ive a ware n ess . racil i ta t i ng c ha n g es in motor c o n t r ol , 1 1 9 Cog n i t i v e d i mension . activity and particip ation restrictions.
15
C og n i tive / m i nd maps , 4 1 4--4 1 5 CoU aborative a p proac h . 6-7. 9 . 4 1 2 back and b i l at era l leg p a i n . 3 3 forearm p a i n preve n t i n g
leisure
activities. 3 7 5
headache. 1 4 2 h i p p a i n . ado lescent. 2 7 1 -2 7 2
l ow ba c k p a i n a n d sciatica, med i c a l e xe rc ise t he rapy. 2 8 0 , 2 8 6 m u l tidiscip l i n a ry wo rk ing 1 8 1 . 1 9 1 peer lear n i n g . 3 9 7 . 4 1 3
.
peripartum pelvic pa i n . chron ic, 3 2 7 . 334
see also Decision making. s h ared Co lJaborative process . reas oning a s , 4. 8 -9 Comm u n ication w i t h doc tor. m i ssed diagnosis. 3 5 6 o f reaso n i n g . deve l o pin g . 4 1 6
I N D EX
Commu nicative ma nagement. 6. 7 . 8 . 2 8 9 c h a n g i n g p a i n beh av iou r 2 8 7 low bac k
and coccygea l p a i n . chronic.
patellofemora l p a i n . professio n a l
d iscussion a n d co mmen tary.
2 1 5-2 1 6 . 2 1 7-2 1 8
.
Craniovertebrai ll exion. a ctive resisted 2 2 6 .
C r i tica l aware ness. i m por ta nc e of. 3 8 4
121 Com pl ex regio n a l pa i n sy nd rom e
l. 3 6 7 type I!. 1 2 4 type
Com plia nce. pa tien t . 1 1 9- 1 2 0 . 1 2 0 . 1 4 2
Critic a l l earn in g theory. 3 8 4 . 3 8 5 C r i tical pedagogy. 3 8 4 a n d socia l action . B o u d . 3 9 0 Critical se lf-re flecti o n . 5 0
413 Con ti n u i n g profess io n a l ue ve lo p men t
,
394 Con t r i b ut i n g [a ctors. 1 7-1 8 back a nd bi la ter a l le g p a i n . 2 8
Dissocia t i ve exercises. low back and
De Bono. l a teral thi n k i n g . 409 Dec i s i o n maki n g . s h ared. 2 8 6 . 404
groi n pa i n el d er ly wom a n . 3 1 3 . 3 1 4 . .
and phy s ic a l i n c a p a c i ty.
u n necessary, 7 2 - 7 3
forearm p a i n preve n t i n g leis u re activities. 3 6 2- 3 6 3 fractu red ra d i u s w i t h me ta l fixa ti on .
233. 237
3 1 6. 3 2 5 s po ndy l o l i s thes is . 3 4 4 De load e d exerc ise . m e d ic a l exe rcise the ra py. 2 8 5 sq u a tt i n g exercise. 2 9 1 . 2 9 6
w i th ca p s u l ar rel axation a n d m o u t h open . 2 5 5 . 2 5 6 . 2 5 7 l on g i t ud i n a l . 2 5 4 . 2 5 6 Dom a i n s o f kn owledge. Haber m a s . 3 8 4 .
385 Domi n an t pain mech an ism s
see P a i n
mec h a n i sms
l o w back a n d coccyge a l p a i n . chron ic .
headache. 1 3 9
Dyn a m ic rotary s tab i l i t y test. 1 6 7
1 04
h i p pa i n . adolescen t . 2 6 2
low b a ck p a in . a c u te on ch ronic.
l ow b a c k
3 4 1-3 4 2
a n d coccyg e al pa i n . c hron i c .
Dewey. reflec t ive thi nking. 3 9 2
1 0 9- 1 1 0
thorax troubles w i t h ten n is
elbow and headache. 3 8
p a i n . chronic. 5 4-5 5 med i a l col la tera l l i ga m e n t re p a i r. pro fess io n a l ice hockey p l a yer 1 8 6- 1 8 7
.
non-m u sc u l oskeletal d isorde r
Di agnosis. h yp othes i s forma t i o n . 1 6-1 7 a n k le spra i n . 1 2 4-1 2 5 back a nd b i lateral leg pai n . 2 8 . 3 1 cran iovertebra l dy s fu nc ti o n fol lowi ng motor veh ic le accident. 2 1 4-2 1 5 . 2 1 8 . 2 2 0-2 2 2 . 2 2 4 facial p a i n . chronic. 2 4 4 . 2 4 9 . 2 5 0 fear avoidance a nd p hysica l incapaci ty.
disorder. 3 5 6
230. 233. 2 3 7 grOin p a i n . e ld e r l y wom a n . 3 1 3-3 1 4 .
motor ve h icle accident. 2 1 5-2 2 8
2 2 7-2 2 8 p hysical e x a min a t ion . 2 1 8 -2 1 9 . 2 2 2-2 2 3 d i scussion a n d commen tary. 2 2 0-2 2 2 . 2 2 3-2 2 5 s u bj ec ti ve exami n a t i o n . 2 1 5 . 2 1 6- 2 1 7
fo rearm p a i n preventing leisure
ac t i v i ti es . 3 6 3 . 3 70 fracture d rad i u s wi t h metal fi x a t io n .
234. 2 3 7 headache. 1 4 1 h i p p a i n . adolescen t . 2 7 3 low back
low back a n d coccyge a l pa in . chronic.
l eg a n d thorax troub les with te n n i s
1 0 7. 1 1 1- 1 1 2 . 1 1 3 . 1 1 4 a n d l e g pa i n . s ubacute. 2 1 3 el b o w a n d head ache. 3 8 . 44--4 7 .
1 04. 1 1 0- 1 1 1 low back a n d leg p a i n . s u b a c u te .
2 0 7- 2 0 8 low back. l e g a n d thorax tro u b l es w i t h ten nis elbow a n d headache.
3 7-3 8 . 40. 4 3 low b ack pain. a c u te on c hronic . 3 4 1 .
3 4 5- 3 4 6 l o w b a c k pain. chronic. 5 2 . 5 4 . 5 6-5 7 .
management. 2 2 5-2 2 7 discussion and comme n tary.
i nc a pac i ty. u nnecessary. 79-8 1 . 8 2-8 3
and coccygea l p a in . c hronic. 1 04 .
Cra n i ocervical flex i o n performed i n
Cran iovertebral dys fu n c t io n fol l ow in g
fear avo id a nce and p hysical
3 1 5-3 1 6 . 3 2 2 . 3 2 4 headache. 1 3 6- 1 3 7 . 1 4 0 hip pain . adolescent. 2 62-2 6 3 . 2 6 9-270
acciden t . 2 1 6
1 43
Eco logica I mode l o f hea l t h ca re . 3 9 5 Ed uc a t i o n . patient
activities. 3 5 8-3 5 9 . 3 6 6- 3 6 9 frac tu r ed radius w ith metal fixation.
Cra n i a l ne rves . cran iovertebra l dysfu n c tion fo l l ow in g car
Eccen tric m usc l e work . 1 7 7
.
forearm p a in pre v en ting leisure
shoulder p a i n . bilateral . l o n g d istance swimmer. 1 6 4 t h orac i c p ain l i m i t i n g activ i ties. 1 5 9 see also P syc h osoc i a l factors Cop i n g a b il ity low ba c k pain and sc ia tica . medical exercise th era p y. 2 7 7-2 7 8 peripartum pel vic pain. chronic. 3 3 1 Cor t ison e i nj ections. l a teral epic ondy l i t i s. 8 7. 8 8
E
u n nece s s a ry 6 9 - 7 0
appe a r i n g as musculoskeletal
s u pine ly in g .
coccygeal pain. c hro n ic . 1 1 9 Distractio n . TMJ disc s u b l u xation
Depres s i o n
g roin pai n . e lderly wom a n . 3 1 6
leg a nd
.
l ow back pa i n . 1 0 9
Degenerative c h a n ges . 1 7
fa c i a l pai n . chronic. 2 4 4
fear a voi d a n ce
足
Ded uctive reaso n i n g . 4 0 5
D
cran iovertebral dysfu nction fo l low i n g motor veh ic le accid ent. 2 1 8
s h o u lder pain . bil a te r a l . l ong
D e e p abdominal muscle activation and
disc hern i a t i on . 3 6 1
Co n fLl'mation b i as . 4 0 8
ten n is p l aye r. 1 9 6 . 1 9 8- 1 9 9 peripartum p e l v ic pai n . c h ro n ic. 3 2 7 . 3 3 0. 3 3 2- 3 3 3
d i s tance swimmer. 1 6 3- 1 64. 1 6 8-1 6 9 thoracic p a i n l imiting activity. 1 5 1 . 1 5 5- 1 5 6 D isable me n t model. 1 7 D isc degeneratlon. 2 0 6 . 2 0 7 D isc d i spl acement. TMJ. 2 4 9 Disc her ni a tion . 5 4 . 5 6 Disc pressure a n d pos ture 1 1 6- 1 1 7 Disc s u b l u xa tio n . TMJ. 2 4 9 . 2 5 0 m a n age ment. 2 5 0-2 5 2 . 2 5 3 -2 5 7
Com pu t ed tomog rap hy. cer v i c a l s p i ne Computer software. re l'lection prompts.
Iff'
58-59
49-50 p a i n . acute o n chron ic. 3 4 4 . 348-34 9 . 3 50 pain a n d sciatica. medica l exerc ise the rapy. 2 8 5-2 8 6 . 2 8 6- 2 8 8 mechanic's e l b ow. 1 0 l per ipartum pe l v ic pain. chron ic. 3 3 5-3 3 6 s hou lder pa in . bi l atera l . l ong d ista nce足
swimmer. 1 6 9 - 1 7 0 . 1 7 2 - 1 7 3
low back p a i n and sciatic a . med ical e xerc i se th e ra py. 2 76-2 7 7 .
2 8 3-2 8 4
thora cic pain l imiting activ ity. 1 5 6 . 1 5 8
E l bow
see Me cha n ic ' s el bow
mechanic's elbow. 8 8- 8 9 . 9 4-9 5
chronic p a i n
n on muscu l oske l eta l disorder
la t e ra l g l i de . 94
-
appearing as musc u l oskel e ta l
disorder. 3 5 3-3 5 4 . 3 5 5
Copyrighted Material
mo b i l i ty testin g. forea r m pain
preven ting lei s u re a cti vit i es . 3 6 5
I N D EX
Electromyog raphic b i o feedback
c l i n i c a l examination. 2 4 5
m u s c l e re-educa t i o n . 1 4 3 . 1 44 Electronic med i a . learn i n g . 4 1 7 E m a n c i p a tory action approac h . ways of
moveme n t impairment s y n d rome.
d iscussion a n d commenta ry. d i a g n ostic i m a g i n g . 2 4 9
Forward reaso n i n g , 40 5 , 4 0 6
d iscussion a n d commen tary. 2 5 0
knowi n g . 3 8 5 Emotion a n d p a i n . 1 0 4 . 3 4 1 . 3 4 2 . 3 5 0
m a n a g e me n t, 2 5 0-2 5 2 . 2 5 3-2 5 4 ,
Empirical-analytic approach. ways of
Fracture spondylolisth esis. 3 44 Fractured rad ius w i t h meta l fixa ti o n . 2 2 9-24 1
2 5 5-2 5 8
knowing. 3 8 5
d i scussion and commenta ry.
m a n a gement. 2 3 4-2 3 6
2 5 2-2 5 3 . 2 5 4 . 2 5 8 -2 5 9
Empowerment empowerment view. adult educatio n .
2 3 7-2 3 8 , 2 3 9 . 2 4 0-2 4 1 phys ica l exa m i n at i o n . 2 3 1 -2 3 3
2 5 3-2 5 7
of i n d i v i d u a l . 3 8 4
o u tcome, 2 5 9
as p a r t o f m a n a gement stra tegy. 1 7 2
s u bj ective exa m i n a tion . 2 4 3 - 2 4 4
d iscussion a n d commentary. 2 3 3 su bjec tive exa m i nation . 2 2 9-2 3 0
discu ssion and c o m m e n tary, 2 4 4
pati e n t involveme n t in reh ab i l i tation
discussion a n d commen tary.
TMJ e v a l u a tio n . 2 4 6- 2 4 8
progTa mme. 2 0 4
2 3 0- 2 3 1
d iscussion and c o m m e n ta ry. 2 4 9
End-feel h a rd . no n-el astic. 2 4. 1
i r r i tated. professi o n a l ten n i s p l ayer.
muscul oskeleta l d isorder. 3 5 5 Endorphins. release of. 2 9 9
Frame of reference.
196. 199
F R S . s p i n a l segm e n t , 3 0 , 3 2
Frustration a t slow progress.
u n l o a d i n g b y tap i ng. 2 0 0 . 2 0 1
Entwistle a n d R a m s d e n . lear n i n g styles.
profes s i o n a l ice hockey player.
Fatigue. genera l . a n d hea l i n g progress.
388. 389
5-h
Fra m i n g er ror. c l i n ic a l reaso n i ng . 4 0 7
Fat pad. i n fra patellar
straight leg raising. n o n
1 8 1-1 8 2 , 1 8 3 , 1 8 9 F u nction a l move m e n t tests.
1 8 6- 1 8 7 . 1 8 9
1 54
Fea r avoid a n c e a n d physic a l i n c a p a c i ty.
E t h i c a l reason ing. 1 9 - 2 0 pr acti c e . 2 2 5 . 2 9 6-2 9 7 .
u n necessary. 6 1- 8 4
assessment i n te r v i ew, 6 3 - 0 5
380 use of rese arc h - a n d experience-based.
d i scussion a nd commenta ry. 6 5 - 6 6
G
man agement. 7 9 -8 3
202
d i sc u ssion and comm e n ta ry, 8 3 -8 5
Ex a m i nation. m a n age m e n t i n corporated i n . 7 3 - 7 4
o utcome, 8 5
G a i t a n a lysis n o n -mus c u l os ke l e ta l d i sord er
physical exa min ation, 7 4- 7 7
Exercise programme 158
a ppearing as m u s c u l os k e l eta l
s u b j ective exa m in a t i o n , 6 1 - 0 2 d is c u s s i o n a n d commenta ry. h 2 - h 3
prescri b i n g . fe a r avo id ance a n d p h y s i c a l i n capacity. u n n ecessa ry.
Fe mo r al a n terior glide s y n d rome. h i p
8 3- 8 4
p a i n . 2 6 7- 2 7 0
E x pec tations o f treatm e n t . promot i o n o f rea l i s tic. 1 4 2
d i sorder. 3 5 4- 3 5 5
d is c u ssion a nd commenta ry. 7 7- 7 9
pacing without provo k i n g frustrati o n .
pateliofemora l dysfu n c tion , 1 9 7 . 1 9 8-1 9 9 G le n o h u meral q u adra n t tcs t. 1 6 8 G l ides. a n terior
Femora l syndromes. 2 6 3 F i brop l a s i a p h a s e o f tissue healing. 1 8 4
390
hy potheses ge neratio n . 1 2 5
rlexion mobi l i ty. restoration
trea tmen t progress i o n . 3 1 8 Experie n t i a l learning. 1 9 1 -3 9 3
E x pe r t c l i n i c ia n . 4 0 3 . 4 0 4-4 0 7 char<lcteristics or expertise. 404 Expiration, 1 0 5 Expla n il ti o n
pos terior. T!'v1J disc
G l o b a l mo b i l i t y tests. s p i n e a nd pelviS .
2Rl
F i s h - b o w l groups. 4 1 6
01'. low b a c k
G l o b a l R a t in g S c a l e . 3 4 8 G l o b a l a n d sem i-gl o b a l exerc ises.
a nd leg p a i n , su bacute. 2 1 2-2 1 3
Experience- b a sed evidence. 2 0 2
a nd
s u b l u x a ti o n , 2 5 7
field work educa t i o n . 3 9 h
Experience a d u l t learning.
discussion a n d commen tary.
staging. b a sed o n o u tcomes .
393
Ev idence-ba sed
264. 267 Forw a rd head posture. 2 1 8 . 2 2 7 . 3 6 4
2 4 5-2 4 6
med i c a l exercise thera py.
Foot c o l o u r change. depe n d e n t pOS i t i o n , sprai ned a n kl e . 1 2 5
3 0 3 , 3 0 4 , 3 0 5 . 3 06 , 3 0 7 G l ucose i nj ecti o n s , s h o u lder pa i n .
rearfo o t , sti ff. 1 9 7
bi latera l . lon g-d i s ta n c e
shock a bsorption. 1 9 9
s w i mmer. 1 6 2 . 1 6 5
Foot dro p. n o n - m uscu loskeletal
G l u te a l muscles. tes ts . movement
of p a i n . 2 8 5
d i sorder appea r i n g a s
i m p a i rm e n t syndromes .
reassess m e n t o f patien t u nders t a n ding.
m u s c u loske l eta l d i s o rder, 3 5 2
266. 268
Forearm p a i n preve n ting l e is u re
1 73 a n d self-manageme n t . 2 1 3 . 3 6 3
see also Ed u c a t i o n . patient
moveme n t impa i rm e n t syndromes. 268, 271
.
� l e � 2 0 9 . 2 0 9-2 1 0 Extension sign . 2 1 1
d i scussion and commen tary. 3 70 .
posterior tra i n ing. pate l l o femora l p a i n in professi o n a l ten nis
3 7 2-3 7 3 . 3 7 4-3 7 6 p hy s ic a l examin ation . 2 6 4-2 6 6
Extremity c o l o u r change. d e penden t positio n . a n kle s p ra i n 1 2 5 .
disc ussion a nd commen tary.
p l ayer. 200. 2 0 1 . 2 0 3 G o a l setting m u t u a l . 3 2-3 3
3 6 6-3 5 7 s u bjec tive ex amina tion , 3 5 8 ,
3 6 0-- 3 6 1
realistic, maladaptive cen tra l ized pa i n .
d i sc u ss i o n a n d commentary.
3 5 8- 3 6 0 . 3 6 1 - 3 6 3
F
Forearm pro n ation. eccen tric c o n tTol . 99
FA BER test . 5 5 movement i m p a irmen t s y n dromes . 265. 208 racia l p a i n . c h r o n i c. 2 4 3 -2 5 8
Form a n d force closure. thorac ic p a i n
li mi t in g activi ty, 1 5 9 Forward b e n d i n g tes t back a n d bil a tera l l e g p a i n . 1 3 0
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2 h 5-2 6 6 .
G l uteus med i u s
a ctivities, 3 5 8-3 7 6 ma n a g e m e n t 3 6 9 , 3 7 1-3 7 2 . 3 7 3
Exte n s i o n in lying w i t h pelvis d i s p l aced
2 79.
2 9 0 . 2 9 1 . 2 9 2 . 29 3 . 2 9 4 . 3 0 2 .
83
5 tech n iq u e ( m a n i p u l a ti ve thrust) thoracic pain limiting activi ty. 1 5 h , 1 5 7 G raded exerc ies , m ed i c a l exercise G rade
therapy. 2 7 9 . 2 8 9-2 9 0 G radual mastery/graded expos u re process m a l a d a ptive centra l i zed pa i n .
II I
I N D EX
Granu lol1broblastic m a terials. te n n is elbow. 8 9 .
drop test . b a c k and bi lateral leg pa i n .
98
29
Groin pa i n . e lderly woma n . 3 1 2- 3 2 5
g ro i n p a i n . e lderly woma n . 3 1 7 . 3 1 8 .
ma nageme n t . 3 1 7 . 3 1 9-3 20 d iscussion .and com men tary. 3 1 8 .
319
med ical practitioner. assessme n t by.
scl erotic c h a nges. ani0' losin g spondy l i t i s , 5 9
321
movements
d i scussio n . 3 2 1
low back pa i n w ith sciatica. 2 8 1
o u tcome. 3 2 4- 3 2 5 d i sc u ssion and commenta ry. 3 2 5
movement impa irmen t syndromes.
physical e x a m i n ation d i sc u ssion and commcnta ry. i n i ti a l . 3 1 4- 3 1 5 on representatio n . 3 2 2- 3 2 3
d iscussion and commentary.
d i scussion a n d commentary. 2 7 3-2 74 physical exami n a t i o n . 2 64-2 6 6 d iscussion a n d commenta ry.
3 1 1-3 1 4 G u t feeling. 3 1 4 . 3 5 6 . 406-40 7
l a teral thi n k i n g stra tegies. 3 74 i n adequ ate testi ng and prema tu re acceptance,
408
physica l exa mi nation fi n d i n gs ,
man ageme n t . 2 7 1 -2 7 2
dbcussion a n d trea tment. 3 2 2
adeq uately, 4 0 7 , 4 0 8 genera t i o n . 5 . 8 , 2 0 0
271, 272
H i p p a i n . adolescent. 2 6 1-2 7 4
s u bj ective exami n a t io n . 3 1 2-3 1 3
fa il u re to generate p l a u s i b le or test
low back p a i n . a c u te on chronic. 3 4 8
synd romes . 2 6 3
represe n t a tion
c ategories. 1 3 . 1 4
264. 2 6 5 , 2 6 6. 2 6 7 . 2 6 8 . 2 6 9 . pain . c a u se s of. 2 6 2
3 1 5- 3 1 7 . 3 2 4
1 7 7-1 7 8 Hypotheses facia l p a i n . c h ro n i c . 2 4 4
joint g r o in p a i n . source o f. 3 1 3 , 3 1 5
320
shoulder. e l ite swimmers, 1 64 , 1 6 9 .
fore arm pain . 3 6 8-3 6 9 testi n g . 7 . 8 . 3 1 . 3 4 . 2 0 8 . 2 7 0-2 7 1 . 3 14. 3 1 7 reassess ment a s . 1 7 3
see also Pa i n mec h a n i sm s : Symptoms. sou rces o f Hypothes is-orien ted method . c l i n i c a l reaso n i n g ,
8
2 6 7-2 7 1 s u bj ective ex amin a t i o n . 2 6 1-2 6 2 discussion a n d commenta ry. 2 6 2-2 64
H
Holistic approach. 3 9 5 cra n iovertebra l dysfu nction fol lowing motor vehic l e accident. 2 2 8
Habermas. critical lea r n i n g theo ry. 3 8 4 .
385
learning. assessment of. 3 9 3
Hagar. experience a n d reflec t i o n . 3 9 2
low back p a i n . a c u te o n c hronic. 3 4 2 .
H a mstri n g shortness
3 S0
low back pain . acute on chron ic. 3 4 9
pateUoremoral p a i n . professional
moveme n t impairmen t syndromes.
ten n is player. 204 peripa rtum pelvic pain. c hronic. 3 2 8
26 5 . 2 6 7 . 2 6 9 Headache. mature a t hlete. 1 3 5- 1 4 8 m a n age men t , 1 4 1 - 1 4 2 . 1 4 2- 1 4 6
thoracic p a i n l i m i ting activity. 1 5 1 Home exe rcise prog ramme
Iliopsoas manual muscle test , movement i m p a irme n t synd romes . 2 6 5 . [ \ ioti b i a l band friction s y ndrome, 1 9 4 , 1 9 9 shortened . ga i t patte r n s . 1 9 9 tigh tness in , pateUofemora l k n ee p a i n . profess ional ten n i s p l ayer. 198, 199 I l l ness scripts. 1 2 . 4 0 6
ankle spra i n . 1 2 8
1mposto r s h i p . 1 0-- 1 1
1 4 6- 1 4 7
cra niovertebra l dysfu n ction fo l l owing
Induc tive reaso n i n g , 4 0 5 . 4 0 6
o u tcome. 1 4 7
motor veh i c l e accident. 2 2 6-2 2 7
n iscussion and commen tary, 1 4 2 .
d iscu:;sion a n d commenta ry.
forearm pain preventing l e i s ure activities. 3 7 1
1 4 7-1 4 8 phys ical ex a mination . 1 3 7-1 3 9
fra ctured rad i u s with metal ilxati o n .
discussion and commentary, s u bjective exam i nation. 1 3 5- 1 3 6 d i :; c u ssion a n d commenta ry.
a lso Cran ioverte b r a l dysfu n ction fo l l owing mo tor vehicle accident
a n d leg pain, s u b a c u te. 2 1 2-2 1 3 pain. acute o n chron ic, 3 4 6 . 3 4 7 . 3 4 8
s h o u lder p a i n . b i latera l . lon g-distance
v a n den Berg mode l . 2 3 4 . 2 3 7
Hea l t h science grad u ates, w h a t is
expec ted. 3 79-3 80 messages. effec l s of. 1 2 7 . 3 3 7 Heart d i sease. referred pa i n , 3 S 9 Hee l rises. low back p a i n w i t h sciatica.
see
also Self- m a n a ge men t
Honey a n d M u m ford . l e a rn i n g styles, 388. 3 89 cen tred education. 3 8 4- 3 8 5 Hyperalgesia
3 tl4
abd uctor and addu ctor muscles. pe l v i c p a i n . 3 2 8
I n frahyoid m u s c u l a t u re. a b n o rm a l i ty. 245 lnfra p a te l l a r fa t pad i r r i tated, professio n a l ten nis player. 1 94, 1 99 u n l oad i n g by t a p i n g .
200, 2 0 1
I n n o m i n a te bone. posterior m o b i l iza t i o n . 335 I n p u t mec h a n i s m s . m a t u re orga n ism mode l . 1 2 pain. 1 5
ankle spra i n . 1 2 4
Inspiration. 1 0 5 - 1 0 6 l n teraction ill1 d com m u n ication w i th
2 5 6. 2 5 7. 2 5 8 H y perm o b i l i ty
Hip
S patterns o f. 1 1
secon dary. 1 7 . 4 0 Hyperbo l o i d . TMJ d i s c remod e l l i n g . 2 5 5 .
2 8 0-1 8 1 Hierarchy o f needs. Maslow.
swim mer. 1 7 0. 1 7 3 . 1 7 4
H u m a n istic, ema n c i patory a n d stu d e n t足
Health-care rrac titioner,. con n icti ng
pa i n . origin of. 2 0 7 I n formation categories e l i c i ted d u ring exa m i n ation .
ten n is p l ayer. 2 0 0 . 2 0 1
im pl ications for educa tion . 3 8 5- 3 8 6
2 30 i n te r vertebral disc proce s s . 2 7 7
a c q u isition , 60
Hea l i n g
Hea l t h care. trends i n . 1 9 4-3 9 5
fra ctured rad i u s with m e t a l I1xati o n .
low back
patel lofemoral knee p a i n , profeS S i o n a l
i n a d u l ts . 2 1 7
I n fl a m m a ti o n
h i p p a i n . adolescent. 2 7 1 and coccygeal pain, chron i c . l l 2 . l l S
1 3 6- 1 3 7 see
2 34, 2 3 5 . 2 3 6. 2 3 9 headache. ] 4 2 . 1 4 4 , 1 4 5
1 3 9-1 40
266.
268. 269
low back a n d coccygea l pa in. chronic. 107
Copyrighted Material
patients . model for. 2 8 7 I n teractio n a l profession a l s . c h aracteristics of. 3 8 7 I n t e ractive computer p rograms. 4 1 4 I n teractive reaso n i n g . 2 8 8- 2 8 9
1f!:l lNDEX I n terc arp al j o i n t exami n a tio n
co mp lex c li n ical probl ems. 2 7 4
fractured rad i u s w i t h meta l fi x a t i o n ,
Local exerc ises . medical exerc ise therapy, 2 7 9 , 2 9 2
craft , 2 5 3 . 4 0 5 e n c apS U lation a n d role o f b io med ical
232 I n tercos tal nerve, neurogen ic p a i n from
knowledge. 1 2
,
151
1 03-1 2 1
experien t i a l n o n - propo s i tion a l . 3 3 7
I n tero ccl u s a l ort hopaedi c a pplia n ce, 2 4 3 ,
o rga niza tion of. 1 1-1 2 , 1 3 3 , 1 8 7 .
2 4 4 , 2 5 2 , 2 5 3-2 5 3 , 2 5 7 , 2 5 8
2 4 6 , 40 5 , 4 0 9 -4 1 0
I n terver tebral d i s c
perso n a l , 1 1 , 3 8 1 , 3 8 2
discussion a n d commen tary.
practice. 3 8 1 -3 8 2
a n d facet j O i n t i mpa Lrmen t 2 4 -hour
professio n a l . 1 1 , 2 4 6 , 3 5 0 , 3 8 1 -3 8 2 .
,
symptom patte r n , 2 8 7 path ology o r p ro l apse low bac k ,
and
prolapse
105-1 0 7 . 109-1 1 1
perso n a l , 3 8 1 - 3 8 2
2 4- h o u r sy m p tom patter n . 2 7 7
Kolb, fou r core le arn ing ca p a b il i ties. 3 8 8 , 389. 398
with sciatica , 2 4-hour symptom
2 1 1 -2 1 3 phy sica l ex a m i n a tion . 2 0 8-2 0 9
L
discussion a n d commen tary. 2 09-2 1 0
i n tracarpal components, dLffere n tiatio n , 232 I n tradiscal press ure. a n d poor posture.
Labra l tea rs. h i p , yo u n g pati e n t s , 2 7 3 Lateral c o l l a te r a l l i g ame n. t pa l p ation
.
TMJ. 2 4 7
La tera l ep icondy l i tis . chronic see
110 I n t u i t i o n . expert th i n k in g , 3 1 4 , 3 5 6 ,
Mecha nic's e l bow, chronic Lateral femora l ep ico ndy le. Lrrita ted
4 0 6-4 0 7 Ischaem i a . ten n i s el bow 8 9
in frap a te l l a fat p a d . 1 9 6
,
Isostation B - 2 0 0 , 3 2 9
Late ral th i n ki n g . 3 7 4 , 4 0 8 , 4 0 9 -4 1 0 La tera l transl a t i o n . mid-thoracic ro tati on , 1 5 3 . 1 5 4 Latis s i m u s dorsi. 3 6 8
J
Learner-centred ed uca tion and h u m a n i s tic educators, Boud . 3 9 0
Jet ski rid i n g . 3 5 8 . 3 6 0 , 3 6 3
Lea r n ers
J O in t alignment ten n i s elbow, 9 9
c haracteristics and styles , 3 8 7-3 8 9
JOin t fixations, tests, th orac ic p a i n
demog raphics. 3 8 9
,
limiting activi ty. 1 5 2 . 1 5 4
Joint hy per m ob i l i ty
how d o learners learn . 3 8 9-3 9 3 preparation for the workplace,
low back and coccygea l p a i n . chron ic.
1 7 7- 1 7 8
Lear n i n g from rellection, 9 - 1 0 . l i felo n g , 3 9 3 - 3 9 4 . 3 9 6 Rogers' ass u mptio n s , 3 8 4 t o lear n , B a tes o n , 3 9 4 tra nsformative. 9 , 2 0 , 1 6 5 , 3 3 5 - 3 3 6
Karate, adol esce nt h i p pa i n , 2 6 1 . 2 6 9 .
see also Education , pa t i e nt Lea.r n ing prog ra mmes
2 70 , 2 7 2
K i netic c h a in qu ad rice ps a n d hamstri n g
factors i nllue nc Ln g pla n n Ln g a n d
exercises, 1 8 4 , 1 8 5 Knee brace, medi a l c o l l a teral ligame n t
implementation, 3 9 8 goa.l s o f. 3 8 3 -3 8 7 Learning theory
repair
choos i ng 3 9 7
immobilizer. 1 8 1
a n d d i scou rse he al th sciences ,
e d u c a tio n . 3 8 0 . 3 8 3 -3 8 7 Leg length in equali ty. 5 6
2 7 1 . 2 72
Leg h ind foot orthosi s . 1 3 1 . 1 3 2 -
profession a l te n n i s p l ayer
Li fe lo ng l earn i ng 3 9 3 -3 9 4 . 3 9 6 .
Litigation a nd sympto m s . 2 1 7 Lo ad transfer. pe lvis . 3 2 8 -3 2 9 . 3 3 3 -3 3 4
K now ledge
cli n ical or craft. 2 3 7
thorax trou bles with tennis elbow a n d headache. 3 6- 5 0
m a n agemen t. 44-4 8 d i scussion a n d commen tary. 4 8 - 5 0 patie n t ' s d escri ption of prob lem , 3 9-40 d i scu ssion and commentary. 40-4 1 phY Sica l e x a m i n a t i o n . 42-4 3 d i s c u ss ion and commenta ry. 4 3 -44 precau tions and red nags. 41 d iscussion a n d commenta ry. 4 1 -4 2 s u bjective exa m i n atio n . 3 6 di scussion a n d commen tary. 3 7-3 9 Low back pa in . acute
on ch ro n ic.
manage m e n t . 3 4 6- 3 4 8 3 48-3 5 0 patient i n terv i ew 3 4 2 - 3 4 3 .
d iscussion a nd commen tary. 3 44-344 phy s i c a l examinatio n . 3 4 4-3 4 5 d iscussion a n d comme n t ary, 34 5 -3 4 6 subj ective exa m i n ati o n . 3 4 0-3 4 1 d i scllssion a n d commen tary. 3 4 1-342 L o w b a c k pain . chron ic over 1 3 yea rs. fu rther i nvesti gation s . 5 7-5 8
.
imp airment syndro mes, 2 6 6 , 2 6 9 , Knee p a i n see Patellofemoral p a i n ,
2 0 7- 2 0 8 L o w b ack . leg and
5 1-60
fu n c ti o n a l . 1 8 4 , 1 8 9- 1 9 0 Knee ex tension i n s i tt Ln g , m ovemen t
d is cu ss ion a nd comme nta ry.
d iscussion a n d commen tary.
con text of, 3 8 2-3 8 3
K
s u bj ective eXa.rJ1 lo a tion. 2 0 6-2 0 7
340-3 5 0
3 9 6-3 9 7
r o les of. 3 9 3-3 9 4
107 shoulders , elite swLrnmer, 1 64 , 1 6 9 ,
clinical. 2 2 2
2 0 6-2 1 3 d iscussion a n d comme n tary.
p atte r n , 2 8 0
b i omed i c a l and
Low back a nd leg pa i n . self-man agement. man agement. 2 1 0- 2 1 1 . 2 1 2- 2 1 3
n u c l e ar m a teria l ca usi n g a u to i mm u ne re a c t i o n . 2 8 4
an d left l e g p a i n . prese n tation.
non-musc u los keleta l d isorder. 3 5 2
Knowles , adult le arn i ng theory, 3 8 5 , 3 9 0
.
1 04-1 0 5 Low back
types of. 1 5 6
C T. 2 8 2 i n ll a med S l ner ve roo t 2 7 9 low b a ck p a i n a n d sciatica. 2 7 7
s ubj ec tive exa m i n a t ion. 1 0 3-104
d isc u ss ion a n d co mme n tary.
405 propositional. profess ional craft a n d
leg p a i n . s u b acute. 2 - 5 . 2 0 7 . 2 1 0
discussion a n d commen tary, phy sical e x a m i n a t i o n . 1 0 5 , 1 0 7- 1 0 9
a n n u l a r fibre tra u m a p a Ln . 1 1 0- 1 1 1 ,
m a n a gement. 1 1 1 - 1 1 3 . 1 1 5 . 1 1 7-1 1 8 1 1 4-1 1 4 . 1 1 6- 1 1 7 . 1 1 9 . 1 1 9-1 2 1
see also Pattern recogn itio n
In terperso n a l i n teractio n s , 3 8 2
Low b a c k a nd coccygea l p a i n . chronic.
Load in g through exercise. rege nera tion of tissues. 2 9 9
Copyrighted Material
d is cuss ion
and com me n tary. 5 8-5 9
ma nagement, 5 9 d i scussion a n d commentary. 59-60 pai n . a n a lysis o f imp act. 53 d i sc uss io n a n d commen ta r y 5 4-5 5 .
p hy si c a l exami n atio n . 5 5 - 5 6
d i s c u s s i o n a n d commen tary. 5 6-5 7 subjective exa m i nation. 5 1 - 5 2 discussion a n d commen tary. 5 2- 5 3
IU'
I N D EX
Low back p a i n a n d sci atica , 2 7 5-3 0 8 m a n a gement, 2 9 1 -2 9 5 , 3 0 1 - 3 0 7
assess i n g early p rog r ession 2 9 7 ,
d iscuss ion
and commentary,
2 8 6-2 8 9 , 2 9 5-2 9 7 , 2 9 7-3 0 1 , 3 0 7- 3 0 8
medical exercise therapy regime n , 2 8 9-2 9 1 o u tcome, 3 0 8-3 0 9
physical ex am i n ation, 2 8 0--2 8 2 discuss ion a n d commenta ry,
Meanin g perspective , patie n ts
Mobi l izations, use on el d erly woman ,
discussion a n d co m men ta ry, 1 0 1
Mod i fied Oswestry Q u e s t ion n a ire, 5 3 ,
d iscussion a n d
comme n ta ry, 9 1 -9 3
M o d i fied Ro land Morris D i s ab i l i ty
d isc u s s i o n a n d
c om m en ta ry, 8 8- 9 0
o u tcome, 1 0 0
low back p a i n ,
a cu te on
3 1 7, 3 1 8
phys ic a l exa m i n ation, 9 1
5 9- 6 0
subjective exam i n atio n , 8 7-8 8 Med i a l
c hro n ic,
3 4 5-3 4 6
extension i n ly i n g , low back and leg p a i n , su bacu te, 2 0 9 , 2 0 9-2 1 0 ,
1 8 0-- 1 9 3
Modified Z u n g Depression I nventory,
Q u es t ion n a i re (MSPQ) , 79, 3 4 8 79, 34 1 , 342, 347, 348, 3 5 0
management, 1 8 2- 1 8 3 , 1 8 4- 1 8 6 ,
Motivation o f p a t i e n t .
1 8 7- 1 8 8 , 1 8 8 - 1 9 0
fea r a v o i d a nce a n d p hy s i c a l d i s a b i l i ty,
c om men tar y 1 9 3 ,
subj ective exa m i na tio n 1 8 0-- 1 8 1
u n n e c ess a ry, 7 3
d iscuss io n a n d co m me n ta ry,
Lumbar spine stabi l ization exercises,
low back p a in , acu te on chronic,
347, 348, 349
retrai n ing , TMJ d i sc s u b l u x a tio n , 2 5 3
1 8 1-1 8 1
rractured rad i u s w i t h
3 1 6 , 3 1 7, 3 1 8 , 3 1 9 , 3 2 2
groin pai n , e l derly wom a n , 3 1 5 Mo t or ve hicle acc i d e n t
M e d i a n a n d rad i a l nerve i r r i ta tio n ,
2 1 0-2 1 1 , 2 1 2
fixatio n , 2 3 0
metal
craniovertebral dysfu nction fol l o w i n g , 2 1 5-2 2 8
that l i m its ac t i vi ty, 1 4 9 Movement ex a m i n a tio n rea r a voidance and phys ica l
Med i a n sternotomy scar, 3 6 7
t h o racic p a i n
Medical exerc i se t herapy, 2 8 9 -2 9 1 expl a nation o f ma n a gement by,
incapacity, u n necessary, 74
2 8 5-2 8 6
low back a n d coccyge a l pa i n ,
graded exercises , 2 7 9 , 2 8 9 - 2 9 0
Lumbope l v ic motion
muscle fu n c t ion , 1 1 6
ou tcome meas u res, 3 0 7-3 0 8
chron ic, 1 0 7
presence o f therap ist, 2 8 7-2 8 8 , 2 8 9 ,
video a n a lysis, 3 3 1 Lumbrical gri p, 2 2 5
290
2 6 2- 2 6 3 , 2 6 7-2 70
man ageme nt, 2 7 1 - 2 7 2
reasoning behind exerc ises chose n ,
rap id recovery, 2 7 3
2 9 5-2 9 7
Movemen t, p ai n related fea r of. 3 3 1
repetitions
McGill Pain
Q ues tio n n a ire, 3 3 2 , 3 4 1
Magnetic reson an ce i m agi n g , osteophyte impinging on cord , 3 2 4
Ma l ad aptive centra l ized pa i n see
Cen tra l mec han is ms p a i n ,
Mand i b le, TMJ d isc
sublu xation
denec tion to right. 2 4 3
-
Movement pattern correction
es t abl is h in g nu mbers of. 2 9 0-2 9 1 rea s o n for n umber of. 2 9 7-3 0 0
sci ati c a , prec a u t i o n s t o m a n a gemen t
rear avoida nce and physical i n c a p a c i ty, .
starting pos itions, 2 9 6 c h a ng in g, 3 0 1
M u l tidiscipl i n ary m a n agement
med i a l c o l l ater a l l i g a m e n t repa i r i n
dissa tisraction w i th, 3 9 5
profess i o n a l ice hockey p layer,
-
328
M a n ipu l ation
Medic a t io n n on complia n c e, low back ,
adverse response to, 2 1 7
cervical spi ne, con tra indication, 3 6 3
a ctivity 1 5 6 , 1 5 7 Man u a l distr a ction , TMJ d isca l thoraci c pain l imiting
subluxation, 2 5 0--2 5 2
M a n u a l techn iq u e, i n ter tester -
rel iabi l ity, 1 5 5
Manu a l therapy d i agnos i s , 1 6- 1 7
Man ual therapy experts c h a racteristics, ,
404
Ma n u a l tractio n , d e lo a d i n g l u mba r spine test. 2 8 2
Meninges, i n cra n i overtebral
d ys fu n c tion fo l low in g car acciden t , 2 1 6
Mentors, c l i n ical practice, 4 1 2 Metacogn i t i o n , 7 , 9 - 1 0 , 5 0 , 4 0 6 c l i n ical structura l diagn oses , l i m i ta tions o f .
h u m a n istic learner-cen tred
prog rammes, c h aracteristics, 3 8 5
Mature orga nism model. 1 2-1 8 , 1 1 7 , 2 1 1
M a x imizing pri nciples , 4 0 7
III
182, 191
posterior pelv ic p a i n , peri pa r tu m , 3 2 7 M u l tifidu s , chro n i c low back coccyge al p a i n
and
exercises to i mprove activation , 1 1 8 i sometric contractio n , 1 0 8
sp ina l s t ab il i ty, 1 0 9
tes t for independent activati on ,
1 08
M u l t i p l e sclerosis, 3 5 3 , 3 5 5 Muscle assessment
control testi n g , forearm pai n preven t i n g leis u re activities, 3 6 5
d evelop i n g s k i l l s , 4 1 6
rac i a l pa i n , chro nic, 2 4 5
lear n i n g from error, 3 2 5
renective thinking, 3 5 0
Metal I1 x a tion a t wrist, perip heral
n eurogen ic mech a n i s m s , 2 3 3
Maslow h ierarchy or needs , 3 8 4
-
pain, acute on c hronic, 3 4 2 , 3 4 7
,
c oc c ygea l p a i n , c hron ic ,
1 1 8-1 1 9
Me d ical model
relaxa tion , 2 5 5
unnecessa ry, 70 low back a n d
284
p aridigm s hift to se l f h ea l i n g model.
muscular rel ations, 2 5 8
Moveme n t i m p a i rment sy nd romes , exa m i na tion to ide n ti fy, 2 6 4-2 6 6
r a n d o m ized con trolled tri a l s , 2 9 8
M
Motor c o n trol
faCial p a in , c h ron ic , 2 4 5
o u tcome, 1 9 2 discussion and
m ed ic a l exercise
therapy, 2 8 7 , 2 8 8
d iscussion a n d commenta ry,
groin p a i n , elderly woman , 3 1 3 , 3 1 5 ,
348, 350 Modified Somatic Perception
,
Lumbar s pine
Questionna ire, 3 4 1 . 3 4 2 , 3 4 7 ,
c o l l a t era l li ga men t repa ir, professional i c e ho c key pl ayer.
1 8 3- 1 8 4 , 1 8 6- 1 8 7 , 1 8 8 , 1 9 1 -1 9 2
L u m b a r i nstab i l i ty, 5 2 , 5 3 , 5 4 , 5 6- 5 7
9 6 , 9 8 , 9 9 , 1 00
d iscussion a n d commentary, 9 8-1 00
2 7 6-2 8 0
chron ic p a in states, 6 2
mec h a n i c ' s e l b ow, 9 3- 9 4 , 9 5-9 6 ,
m a n agemen t . 9 5-9 8
2 8 3-2 8 4
Lower l i m b symptoms, b i l ateral .
M o b i l izations w i t h movement ( M W M s ) ,
5-6
'
subj ective exa m i n a tion , 2 7 5-2 7 6 d iscuss i on a n d com m en t ary,
',
Mecha n ic s elbow, chronic, 8 7- 1 0 1
Mezi row, critical awareness, 3 8 4
M i n i p lyome tric exerc ises, b i l a teral -
shoulder p a in i n l ong d ista nce -
s w i mmer, 1 7 5 M ixed headache rorm, 1 3 9
Copyrighted Material
low b a c k a n d co c cygeal pa i n , c h r o n i c , 107, 108
peripartum pelvic p a i n , chronic, 3 2 9-3 3 0
strength testi n g
i n l ow back p a i n ,
299
Muscle energy tec hn i q u e , h i p nexors, s tre tc hing , 3 3
I N DEX
M u s c l e i m b a l a nce. fore a r m . ten n i s
n o n - m u sc u l oskele ta l d i sorder
el bow. 9 2
Opera n t cognitive-beh a v i o u r a l
a p peari n g a s m u sc u l os keletal
appro a c h . med i c a l exercise
d isord er. 3 5 5
M u s c l e length tests low back a n d coccygeal p a i n . c hro n i c .
t h e ra py.
peripa r t u m pelvic pai n . c h ronic. 3 2 8 t h o racic pa i n l im i ting activ i ty. 1 5 3
1 0 8- 1 0 9 pate l l o femoral knee p a i n .
N e u rom uscu lar adaptati o n . m ed ic a l
professi o n a l te n n is player.
exerc ise t h erapy t o pro m o te.
1 9 7- 1 9 8
299
M uscle l e s i o n . cra n iovertebra l
s u b l u x atio n . 2 5 8 Orthotics foot. patellofemoral knee pain i n profeS S i o n a l ten n i s pl ayer. 1 9 4 .
Ne u ro m u sc u l a r contro l . sca p u l ar
195. 199
knee brace
synergists. 1 3 8- 1 3 9
d y s function fo ll owing motor ve h ic l e accide n t . 2 2 0
t h erapcu tic exercise t o i mprove.
p a te U o [emo ral p a i n i n profess ion a l
J 39-140. 1 4 1- 1 4 2 . 1 4 6
M u s c l e wea kness a n d nerve root p a t h o l ogy. triceps a n d biceps. 3 6 9 M u s c u lar fu n c t i o n . e ffects of p a i n a n d
ten n i s p l ayer. 1 9 3
N e u ro n a l plasticity. 3 7 5
Oswestry Low B a c k Pa i n D i s ab i l i ty
N e u ro v a s c u l a r i n sta b i l i ty. a o kle spra i n . 1 2 5 . 1 2 6-1 2 7 . 1 2 7
swel l i n g . 2 9 8 M u s c u l oskele ta l c a u ses. g ro i n p a in . 2 6 2 M u s c u l oske l e t a l d isord e r
fo rea r m pain preventing l e i s u re a c t i v i t ie s . 3 6 1 - 3 6 2
m u sc u loskeleta l d is o rder
leg a n d t h o r a x tro u b les
low back and leg pain . subacu te. 2 1 1 l o w b a c k pa i n . acu te on c hro n ic . 3 5 0
with te n n i s
e l b ow a n d headache. 3 7
appeariog as m u s c u l oskeletal
5 ':>- 6 0 O u tcome m e a s u res
l ow b a c k
presenting a s see N o n 足
Scal e . 3 0 7 Oswestry Question n a ire . mod i lied . 5 3 .
Nociceplive dom i n a n t p a i n . 1 5 . 1 7- 1 8
n o n - musculoske letal d i sorder
med ica l exerc ise therapy. 3 0 7- 3 0 8 objective. therapeu tic d y n a m i C
p a i n . acu te o n c hro n i c . 3 4 3
disorder M u sc u loten d i n o u s p a t h o logy. mec h a n i c ' s
m agnetic reso n a n c e i m aging. 2 50
tennis elbow. 8 9 thoracic p a i n l im i ti n g activity. 1 5 1
elbow, 9 9
O u t p u t mec h a n i s m s . m a t u re orga n i s m
N o n - m u s c u l oske l e t a l d isorder
m o d e l . 1 2 . 1 3 . 1 5- 1 6
appearin g a s muscu l o s ke leta l
Overactiv i ty-u nderactiv i ty cyc le.
d i s o rder. 3 5 2 - 3 5 7
N
286
Orthostatic rest pos i t i o n . TMJ j o in t
m a l o daptive cen tral ized pa i o . 8 1
m a n a geme n t . 3 5 5 - 3 5 6
O x y toc i n . 2 8 7
d i s c u s s i o n and commenta ry. 3 5 6 N a rra t i ve reaso n i n g . 5 - 7 . 6 3 , 2 6 4 . 2 8 8 a n d comro u n i c a t i ve m a n ageme n t . fa c i a l pa i n . c h ronic.
244
6. 8
o u tcome. 3 5 7 p hysic a l exa mination . 3 5 4- 3 5 5 d i sc u s s i o n a n d c o m m e n t a ry. 3 5 5
Pilin
discu ssion a nd c o m m e n t a ry.
low b a c k a n d coccygea l p a i n . chron i e . 1 2 1
3 5 3-354
low back p a i n . a c u te on c h ro n i c . 3 4 } Neck flexors. tes t i n g pattern o f
1 0 - box sca le. 3 0 7
Non -propos i t i o n a l k n owledge. 1 1
c h ro n ic. common consequences. 80
see also Perso n a l k n owledge;
components . 3 4 9
P r o fessi o n a l cra ft knowledge
a c t i v a t i o n , 1 3 8- 1 3 9 Neck p a i n a nd h e a d a c h e . 1 3 5 . 1 3 6- 1 3 7
of mec h a n ical or c h e m i c a l origi n . 2 0 7 .
N o n - s tero i d a l a n ti-i n rI a m mil tory drugs m echa n ic ' s e l bow. 8 7 . 8 8
N e u r a l m o b i l i ty. groin p a i n . e lderly
pa tel l o femora l p a i n . p r o fessi o n a l t e n n i s p l ayer. 1 9 5
wom a n . 3 1 3 . 3 1 5 . 3 1 6 . 3 2 3 . 3 2 5
208 m o d i fied Oswestry Q u estion n a ra ire.
Neck retraction exercises. 3 7 1
5 3 , 5 9-60 m u l tiple factors that can trigger. 83
Neuro a n a tomica l l i n ks . upper l im b p i n s
n o n - thre a te n i n g . concept of. 44-4 7 ,
a n d needles reproduced b y
120
abdom i n a l stretc h i n g . 3 7 1 - 3 7 2 . 3 7 2-3 7 3
red u c tion a n d d esensitizing
o
strategies. m a l ada ptive
N e u ro b i o logy. 49
c e n trali zed p a i n . 8 3
N e u rodynam ic m o b i l iz a t i o n for scia tic a n d peron e a l n erves. 1 2 7 .
1 29
sou rce o f see Symptoms. source of
Ober's test, 1 9 6 . 1 9 8 , 2 6 8 O b l i q u u s exter n u s abd o m i n i s . low b a ck a nd coccyge a l p a i n . c h ro n i c . 1 0 5 .
N e u roge nic p a i n . 70 i mp a c t on c e n tra l nervous system. 3 6 2 N e u ro i m m u n e syste m . s tre s s . response
Po in c o n t i n ge n t treatment appro a c h . 2 78
Occ ipitofron tal h e a d a c h e fo l l ow i n g car
forearm p a i n preve n t i n g l e i s u re activities. 3 6 5
Occ u pation a l inj uries
a n k le spra i n . 1 2 4- 1 2 5
back a n d bi late r a l leg pain , 2 8
2 0 6- 2 1 3 m ec h a n i c ' s e l bow. 8 7- 1 00
323. 324 h e a d ache. 1 3 8 . 1 3 9
fea r avoid a n ce a n d p hy s i c a l
profess i o n a l sportsmen
low back
344, 3 4 5
p a i n w i t h sciati ca. 2 8 ()-2 8 0 thorax a n d l e g tro u bles w i t h ten n i s el bow and Ile a d a c he. 42-4 3
in c a p a c i ty. u n necessa ry. 6 6 . 6 7 .
ice h o ckey p l ayer. 1 8 0-- 1 9 1
69. 70
ten n i s p l ay e r. 1 9 4- 2 0 4
forearm p a i n preven t i n g leisure
Open-heart su rgery. fo rearm p a i n preve n ti n g lei s u re a c t i v i ties .
3 5 9 . 3 6 1 . 3 6 2 . 3 74
Copyrighted Material
see Body c h a r t
Pain mec h a n is m s , 1 3 , 1 5- 1 6 . 1 7 .
low back and leg pa i n . subac u te.
g ro i n pain. e l d e r l y wom a n , 3 2 2- 3 2 3 .
Pa in d i ag r a m
Pain m a p e v a l u a tion. TMJ. 2 4 6- 2 4 8
accident. 2 1 7
fac i a l pa i n . c hro n ic. 2 4 5
and symptoms
c l a ss i lication o f patient presentation med i c a l e xercise t hera py t o t re a t. 2 R 6
o f patie n t a s sessme n t . 4 1 2
a n kle spra i n . 1 3 2
Pain be h . w i o u r
accord i n g to. 2 7 8-2 7 9
106. 107. 1 1 7 Obser v a t i o n mecha n i c ' s e l bow. 9 1 -9 2 . 9 3
to. 1 6 N e uro logical ex a m i n ation
pain, acute o n chronic.
p
s u bj ective exami n a t i o n . 3 5 2 - 3 5 3
g r o i n p a i n . elderly woma n . 3 1 4
3 5 8.
activities. 3 6 1 -3 6 2 . 3 6 8 . 3 7 5 fra c t u red radius w i t h mela l fi xa t io n . 233. 2 37
I N D EX
groin pa i n . elderly woma n . 3 1(-; . 3 1 7 . headache.
Peer l e arn i n g . 3 9 7 . 4 0 7 . 4 1 3
Pass ive s tretch i n g medi al c o l l a te r a l l i g a m e n t repa i r.
322
137
1 8 8- 1 8 9 , 1 9 1
a n d coccyge a l p a i n . c h ro n ic. 1 0 4 .
llO leg a nd thorax tro u b l es w i t h ten n i s pa i n . a C LI te o n c h ronic. p a i n . c hronic.
abdom i n i s . 1 1 2
54
343
Pel v i c glrdle. p a i n referred to, 2 6 2
fol l owing car accident. 2 2 6
Pe l v ic j oints
profes siona l ten n i s pl ayer. 1 9 8 P a te l l ofemoral p a i n . pro fess i o n a l te n n is
thera py. 2 8 3
m a n a gement. 2 0 (}--2 0 1 . 2 0 2 - 2 0 3
89. 92. 95
appea r i n g as m u s c u loske l etal d i sorder. 3 5 3 -3 5 4
2 0 1 - 2 0 2 . 2 03-204
of p a i n see P a i n perception Peripa r t u m pe l v ic pain. chron ic. 3 2 6-3 3 7
d iscussio n a n d commenta ry. 1 9 8-200
fu rther i nvestigati o n s . 3 3 1- 3 3 2
swi mmer, 1 6 3-1 6 4 . 1 6 8
s u b j e c tive exa mi n a ti o n . 1 9 4 . 1 9 5
t horacic pa i n l i m i ti n g acti v i ty, 1 5 0
d iscuss i o n a n d comm e n ta ry.
m a n a gement.. 3 3 4- 3 3 5
low b a c k pa i n . acute o n c h ronic. 3 4 2
Path o b i o l ogical mechan i s m s . 1 4- 1 6
l o w back p a i n a n d sciatica, 2 7 7 . 2 8 0
el bow p a i n . s tructura l sou rces. 9 0
Pain pa tter n . reprod u c i b i l i ty. 2 7 8
hypotheses i n c l i n ical reason i n g . 1 8 7
Pain perception
low b a c k . leg a n d thorax trou b l es with
34 1 . 3 4 2 . 3 50
ten n i s el bow a n d head ache. 3 7
55
Pa i n provocation tests. pe r i pa rtum pelvic p a i n . c h r o n i c . 3 2 9 reha b i l i t a Li ol1 programme. 1 8 8
Pa i n s La te . cen tra l sen s i t i v i ty. g ra p h i c Jescriptio n . 46
th ora cic p a i n l i m i ting activi ties . 1 5 0 Patholog i c a l seq u e l a e . p reve n t i o n of poss i b le. 2 2 8
Pa l l i a tive
tTcatmen t i n muscle control
problem. 1 7 6
9
patho b i o logic a l c h a n ge s .
Pati e n t p a r ticipat i o n see Col l aborative approach Pa tient u nderstanding. 3 7 S c h a n g i n g. 8 . 2 8 6-2 8 8
p a t hol ogy. 2 0 7
l o w b a c k p a i n . a cute o n chron ic. 3 4 3
Pa per- based a nd ora l cases. 4 1 4-4 1 5
i n sel l'- m a n agemen t . 1 7 2
spontaneous. u p per limb. 3 7 3 Pass ive movement testing cra n i overtebra l dysfu n c tion
Pero n e a l nerve i nvolveme n t . a n k l e
Patient-ce n tred c l i n ical reason i n g .
Person a n d pro b l e m , u ndersta n d i n g .
3-4
Pattern reco g n ition. 7-8 . 1 2 5 . 2 71 . 40 5 . 4 0 6 . 4 0 9 -4 1 0
fo lloW i n g car accid e n t . 2 2 2-2 2 3 .
a n k l e spra i n . 1 2 5
2 2 3- 2 2 4
arm p a i n . 9 5 . 1 0 0
fa c i a l p a i n . TM ) . 2 4 8
b i as in . 1 6 9
groin p a i n . elderly wom a n . 3 1 7
cra n i overtebral dysfu nc t i o n fo l i ovlTing
headache. 1 3 8 low b a c k a n d coccygea l p ai n . c hro n i c . 1 0 7 leg a n d thora x t ro u b l es with ten n i s
e l bow a n d headache. 4 2 pain. acute on c h ro n ic. 3 4 5 . 3 4 8 movement impa irment synd romes . 264. 2 6 6 . 2 6 7 . 2 68. 2 72 p a te l lo femoral p a i n . professio n a l ten n is player. 1 9 7 peri p u r t u m pel v i c p a i n . chro n ic. 3 3 0 shou lder pa i n . b i l a tera l . l o n g d ista nce s w i mmer. 1 7 4-l 7 5 . 1 7 8 t h oracic p a i n l i m i t i n g a c t i v i ty. 1 5 2-1 5 3
4- 5 . 2 8 0 . 3 4 3 - 3 4 4 c l i n i c a l reaso n i n g strate g ies t o m a nage. 2 8 8 Perso n a l k n o wledge. 1 1 . 3 8 1 . 3 8 2 l ow b a c k p a i n , a c u te o n chro n i c.
350 Perspectives
motor veh i c l e acc i d e n t . 2 2 0- 2 2 2 facia l pa in . c h ro n ic. 2 4 9 forea r m p a i n preve n t i n g leisure activities. 3 6 3 groin p a in . elderly wo m a n . 3 1 4 gu t fee l i n g . clinical i n tu itio n . 3 5 6 headache of
spra i n . 1 2 4 . 1 2 5 . 1 2 7 n e u romobilization exerc ises. 1 2 9
tissue h e a l i n g , 2 3 4 . 2 3 7
also Ed u c a t i o n . p a t i e n t
l l0
sympto m s . i n tervertebra l d i sc
Panel disc l l s s i o n . 4 1 6
see
and coccygea l p a i n .
Periphera l iza tio n . back a n d leg
education t o rev ise. 3 6 3
38
23 )
Pe r i p h e r a l s e n s i t i zation u n d cen tra l ada pta tions. chro n ic low b a c k
Pancoast ' s tu m o u r. 3 5 9
scree n i n g questi o n s ,
1 5 . 1 7. 3 7 of
n e u rogen ic pa i n .
trau m a . i ncreased r i s k
ch ro n i c pa i n . 3 3 5-3 3 6
Parasthes i a / u n aesthes ia
3 2 7- 3 2 8 Peripheral nervo u s system
Pa tient prese ntati o n , reth i n k i n g . 4 1 7
Pa i n-rela ted fear o f movement. 3 3 1
d i sc u ssion a n d commen ta ry,
Pa tient com p l i a nce. 1 1 9-1 2 0 . 1 4 2
Paln -con tin ge n t trea t m e n t approac h , 295
d i scussion a n d com m e n t ary. 3 3 7 p hysica l e x a m i n ation , 3 2 8-3 3 0
Pa tie n t ed ucation see Ed u c a t io n , patie n t Pat.ient learn i n g .
Pa i n to lerance, l ow, 1 8 2 . 1 8 3
3 3 5- 3 3 6 ou tcome. 3 3 6
s u bjective ex a m i n a ti o n . 3 2 6
3 3 2- 3 3 3
Pain repor t i n g . inaccu rate. a n d ath l ete's
d iscussion a n d c o m m e n tary.
d i s c u ssion a n d comm e n ta ry. 3 3 0
peripartum pelvic p a i n . chronic.
a n d psychosoc i a l stat u s .
d iscussion a n d c o m m e n t a ry. 3 3 2- 3 3 4
1 9 4- 1 9 5 , 1 9 6- 1 9 7
mood a n d emotio n . effects o r. 1 04 .
Pe l vi c l a ndmark symmetry. 5 5
o f experience. patient's. 4 8 --4 9
phY S i c a l exami n a ti o n . 1 9 7- 1 9 8
Pain pattern. 2 4 - h o u r
exe rcise therapy. 2 8 2
Perception
o u tcome. 2 0 4
s h o u l d e r p a i n . b i l a tera l . l o n g d ista nce
low b a c k p a i n with sciatic a . med i c a l
Pe lviometer. 5 5
d i scussion and comm entary.
non-muscu loske leta l disorder
l o w back pai n . c hronic. 5 5 . 5 6
peri p a r t u m pelvic p a i n . c h ro n ic. 3 3 0
pl ayer. 1 9 4- 2 0 4
p a i n a n d sciatic a . med i c a l exerc ise mech a n ic's e l bow.
cran iovertebral dysfunc tion Pate l l ar positi o n . patellofemoral p a i n .
e l b o w and h e a d a c h e . 3 8 . 4 0 . 4 3
Pel v i c noor muscles. con tractio n . isolation of tra nsversus
u p per tho racic e x ten s i o n .
low b a c k
""
mixed form. 1 3 7. 1 4 7. 1 4 8
awareness o f new. 1 0- 1 1 patien ts ' . 5 - 6 .
14
therap ists ' . 5 Physica l exa m i n a t i o n favo urable fi n d i n g s . m a l a d a p tive c e n tra l ized p a i n . 7 8 n e u ro m u sc u l oskeletal abnorm a l i ties detecte d . 1 6- 1 7
h i p pa i n . adolescent. 2 7 1
as trea tme n t . 44
l ow back
and tre a t. m e n t . prec autions a n d
a n d leg pain, su bacute. 2 0 8 p a i n . a c u te o n c hronic. 3 4 1 p ai n with sciatica. 2 8 0 p a te l l o femora l pai n . profeSSional te n n i s p l ayer. 1 9 4- 1 9 5 thoracic pain limiti n g activ i ty. 1 5 1 . 1 5 5
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contra indications. 1 8 P hy s i c a l i m p a irmen t a n d level o f d i s a b i l i ty c o n s id e ration of serious p a t h o l ogy. 3 1 6. 3 1 7 low back p a i n w i t h sciatic a . 2 8 3
I N DEX
P hys ical i m pa lrment a n d l evel o f d i s a b il i ty (contd) stru ctu r es / tissu e sou rces associated .
Predictive reason i n g . 1 8- 1 9
Pregn a n c y. onset o f p a i n i n relation to. 327
1 6- 1 7
Prev ious treatmen t
P hysical a n d p syc h osoci a l factors. i n te r
足
rel a t i o n s h ips. 3 3 4
a n kle spra i n , 1 2 3 back a n d b i l a teral leg p a i n , 2 7-2 8
cra n i overtebral dys fu n c tion
Pl y ometric ex er c ise s m e d i a l c o l l a tera l l igament repa i r. profe s s i o n a l ice
1 90 . 1 9 1
hoc key pl ayer.
following motor ve h icle
.
swi mmer, 1 7 5 , 1 7 6 - 1 7 7 Podoscope examination. we ight be a ri n g assessment, 1 3 1 . 1 3 2 . 1 3 3 Posi tio n a l tests. 1 5 4 Posterioanterior passive accessory i n te rvertebra l m o ve m e n ts ( PAV I MS ) . groin p a i n . elderly woma n , 3 1 5 . 3 1 6 , 3 1 7 Posterio i n ferior sy n o v i a l mem brane.
'I'MJ. 247
fe ar avo ida nce a n d physical incapac ity. u n n ecessary, 6 3 , 6 4 , 6 5 l o w back a n d coccy g e a l pain. c h r o n i c . 1 0 3 . 1 04 pain, acute on chronic, 3 4 0 p a i n . c h r o n ic. 5 1
palpation, 24 8-249 .
Posterior pelvic p a i n . 3 2 7
provocation tes t . 3 2 9 ty p i c a l a ssess m e n t fi n d i n g s , 3 3 3 Posterosuperior synovial membrane, TMJ p a l p a tio n . 2 4 8 Postural correction c h ro n ic l o w back a n d coccygea l p a i n , 116 TMJ d i s c s u b l u x a t i o n , 2 5 8- 2 5 9 Pos t u r a I exercises
189. 193
low back p a i n , a c u te o n chro n i c . 3 5 0
maladj ustment. testing fo r. 3 3 1 -3 3 2
p a i n rating. 60
presen ting as m u s c u loskeletal p a te l lofe mora l p a i n , pro fe ss iona l te n n i s p l a ye r, 1 9 5 327
see also P s ychosoci a l factors Psyc hosocial factors. 8, 1 4 . 1 9 a d o l escen t h i p p a i n . 2 6 3
facial p a i n , chron ic. 244
frac t u red rad i u s with meta l fix a t i on
115 neurom u s c u l ar re-educati o n . head ache o f m ixed form. 1 4 1 . 1 4 2
Pos t u r a l i m pa i rm e n t
s h o u lder pai n , b i l a tera l . long-distance
swi m m e r, 1 6 2 , 1 6 4- 1 6 5
he a d a che, 1 3 7 low back a n d coccygea l pain. chron ic, 1 04 .
thoracic pain l i m i ti n g activity. 1 4 9
Pro b l em-so lvers, becom i n g . 3 8 6 P ro ced ura l manageme n t, 6 . 7 Procedu ra l rea soning. 3 0 1 Processing, p a i n i n p u t , I S Professiona l a u tonomy. 3 8 0 P rofe ss i onal craft k n o w ledge, 1 1 . 2 4 6 .
120 pa i n , a c u te o n c h ronic, 3 4 9- 3 5 0
m ech a n i c s elbow, 9 0-9 1 patel lofemoral p a i n in profeSSional te n n is player, 2 0 3-204 perip a r t u m pe l v i c pa i n , c hro n i c , 3 2 7 . '
Profes s i o n a l practice. Schon . 3 9 5
331. 333. 337
P ro fe ss io n a l soci al ization. 3 8 2-3 8 3 . 3 9 6 P rog n o s i s , 1 8- 2 0 a n kle s pr a i n 1 3 3
scree n i n g , 2 1 8 , 2 4 1 thoracic p ai n l i miting activ i t y. 1 5 0 P u b i c sy mp hy s i s . rad iographic v i s u a l is a tio n . s ac ro i lia c joi n t
.
mob i l i ty. 3 3 1
cran iovertebral dysfu nction follo wing
means to avo i d pai n . 2 8 3 Postu ra l a n d movemen t abnorma l i ties,
motor vehicle accident, 2 2 7-2 2 8 . 228 fe a r avo i d a nce a nd phy s i c a l i ncapacity.
1 5- 1 6
u n n ecessa ry, 8 5
Postu re fac i a l pain. c h ro n i c 2 4 5 . 2 5 8-2 5 9
forearm pain p re venting leisure
fo rea rm p a i n p reven ting l e i s u re
acti v i ties. 3 5 9 , 3 7 5 fractu red rad ius with metal fi xatio n .
,
activ i ties, 3 6 3 . 3 6 4 forward head posture, 2 1 8 . 2 2 7 , 3 6 4
headache. 1 4 6
h e a d a c he . 1 3 7- 1 3 8 , 1 4 1 , 1 4 2 . 1 4 3
l o w back
leg a n d thorax tro uble s with ten ni s e l bow a n d head ac he. 4 2 p a in a n d coccyg e a l p a i n , chronic, 105, 105 106. 106. 1 1 6 -
leg a n d t h o r ax troubles w i t h ten n is el bow a n d headache. 3 8 pain, acute o n chron ic, 3 4 6 p a i n with sci atic a , medical exerci se
mec h a n i c ' s elbow, 9 1 -9 2
and movemen t abnorm a l i ties, 1 5- 1 6
non-muscu loskeletal disorder
ther a py, 2 8 1 . 2 8 3
,
Practice epistemol ogy. 3 8 1 . 3 9 8
appea r i n g a s musculoskeletal
P ractice knowled ge, forms or. 3 8 1 -3 8 2
d i s o rder. 3 5 6
P rec a utio n s a nd contra indic atio n s to exa m i n a ti o n and management. 1 8 forearm p a i n preven t ing leisure a ct i vities. 3 6 3 thoracic p a i n l i m i t i n g activities ,
Q u a driceps lag. re ha b i l itation of med i a l col. l ateral l i gament repair, pro fess i o n a l ice hockey pl ayer. 1 8 5 . 1 8 6 strengthe n i n g exerc ises . .worsen ing
and leg p a i n . s u b a c u te , 2 1 3
therapy 3 0 8 med i a l collateral ligament re p air, professional ice hockey player, 1 8 2
p a i n a nd sciatica. med ical exercise
Q
241
grOin p a i n , elderly woma n , 3 1 4 l o w back
.
241
3 5 0, 3 8 1-38 2 , 405
c hronic low back and coccyge a l p a i n .
1 5 0- 1 5 1
232
back p a in w i t h sciatica. medical ex erc i s e therapy. 2 8 2 Psychological a spec ts fe a r avo id a nc e a nd p hy sica l incapacity. unnecessary. 6 5 . 73 i nj u ry in profe S S i o n a l ath letes. 1 8 3 . low
n o n - m u sc u l os ke leta l d i sorder
peripar t u m pelvic pain. chro n ic. 3 2 6 ,
z o n e) , 2 4 8
fractu red radius with metal flxation.
mec h a n i c ' s e lbow, 8 7
d is order. 3 5 3
Posterior l i g a me n t TMl (disc bilam i n a r
Provoc a tio n a n d a l l e v i a tion tests
acc i d e n t , 2 1 7 fa c i a l p a i n c h ronic. 2 4 3 . 2 4 4
shou lder p a i n . b i l a tera l . l o n g-distance
P roprioceptive and con trol exercises med i a l col l a teral l i ga me n t repa ir, profes s i o n a l ice hocke y player. 1 8 4- 1 8 5 , I S S Prosser. responsi b i l i ty to commu n i ty. 386
shou l der p a i n , bilatera l . lon g -d i s t a n ce
k nee
symptoms, 1 9 6
Q u a druped roc k i n g b a ckward s .
movement impairment s y n d ro m es , 2 6 6 , 2 6 9 . 2 7 1 . 2 8 1 Que bec Back Pain Disabi l ity Sca le. Du t c h version . per i p a r t u m p e l vi c p a i n , chron ic. 3 3 2
Questionna ires see Self- re por t i n g form s
R
s wi m m er, 1 7 7-1 7 8 Propositio nal lmowledge, 1 1 , 3 8 1 . 3 8 2 low back pai n . acute o n chronic. 3 5 0 a n d non-propositi o n a l . comb i natio n , 383
Copyrighted Material
R a d io-u l n ar j o in ts , fractured rad i u s
with
meta l fi x a t i o n differe n t i a t i o n from int e rc a r pal j o ints. ex a m i n a t i o n . 2 3 2
I N D EX
rec r u i t i n g isometric a lly a n d then
Respiration
d i s ta l . 2 3 1 mo b i l i zation o f prox i m a l a n d d istal.
conce n tri c a l ly. 1 5 7 .
dysfu n c tion , forward head pos ture
S e l f-man ageme n t
postural compensation for. 1 0 6
prox i m a l . 2 3 2 Radioca r p a l j o i n ts. fra ctu red radius
Retinacu l a r. testing su perficial tissues. Retrod iscal tissue i n sertion . TMJ.
236. 238 Rad i u s . frac t u re see Fractured rad iu s
247
m o t o r v e h i c l e accident. 2 2 h- 2 2 7 education a n d ex p l a n a t io n . 2 1 3
p a lpation. 2 4 8 Retrodisc i t i s ,
w i th meta l fixation Ramsd en. deep a n d surrace approac hes
TMj , 2 4 9
low back a n d coccygea l p a i n . c h r o n i c .
Retrotorsion o f h i p s . 2 6 9
1 14 l ow b a c k and leg p a i n . su bacute see
R ibs, biomec h a n ics. thoracic [J a i n
to learn i n g . 3 8 9
Low back a n d leg p a in . self足
lim i t ing activity. 1 5 1
Reasoning
4 . 8-9
as collab orative process .
d i agnostic versus n a r r a t i ve . 6-7
m a n a gement
Ro a d tra ffic accide n ts cra n i overtebral dysfu nction rol lo w i n g mo tor veh icle a cc i d e n t . 2 1 5-2 2 8
evolv i n g natu re o r. 2 7 0 a n d k n owledge. 1 1- 1 2
rra ctured rad i u s w i t h meta l fixa t i o n .
9 - 1 () role of rea ssessmen t i n . 7 Reaso n i n g process. ex pert. 40 5-4 0 6
Rogers. h u m a nistic learner-cen tred
Rea ssessment
Ro l a n d Morris D i s a b i l i ty Q u estion naire.
as reneclive process .
clinical patterns. re appra i s a l i n decision-ma k i n g . as
18
o r. 2 k O
form of bypothesis test i n g . 1 7 3 . 2 3 8
2 2 9-241 program mes . characterislics.
385
mod ified . 3 4 1 . 3 4 2 . 3 4 i . 3 4 8 . Rotator cu rf
3 50
m a n oe uvre. 1 6 7 . 1 7 0
and treatment prog ression. 2 3 7 Rectus abd o m i n i s
l o n g-dista n ce swimmer. 1 6 4
i ncapacity, u n n ecessary. 7 3 medial col l a teral ligament repa i r, professio n a l ice bockey player. non-muscu loskeletal disorder appearing as musculoskeletal Z u n g Depression [nd ex Score. 3 4 6
3 4 8 , 3 50 as o u tcome measure s . low back p a i n .
coccygea l . from l u mbar spine or sacroili ac j o i n ts . 1 0 4
a c u te o n c h r o n i c . 3 5 0
form closure and force closure. 2 9 6 . 333 i m p a irment. back a n d b i l a teral leg
c l i n i c a l pattern d iscovery a n d eva l u atio n . 2 3 9
radiographic visu a l i sation
learn i n g from clinical experi ences . 3 50. 3 9 2 renection-about-acti o n .
1 0 . 40 5
10. 405
Renective d i a ry. 4 2 0 o f cU n i c a l p atter n s . 4 1 2-4 1 3 Reproducibil i ty o f symptoms fo rearm pain preventing leisure activi ties . 3 6 6 . 3 6 8- 3 6 9 d uring treatment. 3 6 9-3 6 9 g ro i n p a in . elderly woma n . 3 1 4 . 3 1 5 . 316 symptoms a n d p a in behaviour. 2 78 Research-based evidence. 1 0 0 . 1 1 7 . 2 0 2
Sequ ence tra i n i n g. fractured ra d i u s with meta l flXati o n . 2 3 8 . 2 3 9 . 240 S h o u l d e r pa i n . b i l a tera l . l o n g-distance swimmer. 1 6 1 - 1 7 9
or. 3 3 4-3 3 5 S c a p h o i d . tr a n s l a tory vo l a r g l i d i n g
ma n a gement. 1 6 9-1 7 2 . 1 7 3 - 1 7 5 d iscussion a n d comm e n t ary. 1 7 2 - 1 7 3 . 1 7 6-1 7 8
motion . i s o l a t i o n from s p i n a l m o t i o n .
outcome. 1 7 8-1 7 9 physical e x a m i n a t i o n . 1 6 6---1 6 8
1 5 7-1 5 8 shoulder p a i n . bil atera l . l o n g d i s tance swi mmer. 1 6 6 . 1 6 7- 1 6 8 . 1 6 8 . syndergists, activation
discussion a n d commentary. 1 6 8- 1 6 9 s u bjec t ive e x a m i n a t i o n . 1 6 1 - 1 6 3 d iscussion a n d comm e n t a ry.
1 70 . 1 7 1 , 1 7 4
prognosis. m a k i n g . 8 5
rac i a l pa i n . chro n i c . 2 4 5
S h ock absorption. 1 9 9
m o b i l i ty. 3 3 1
protraction and e l evation , 3 7 4
errors. l e a r n i n g from . 3 2 5
thera py. 2 7 9 . 2 9 2 . 294. 3 0 2 , 3 0 3 . 3 04 . 3 0 5
l o w back p a i n w i t h sciatica . 2 8 1
111
Sca p u l a
Re nection. 9 - 1 0 , 1 9 3 . 4 1 1
Semi-global exerc ises, medical exerc ise
S e n si b i l i ty testing
pa i n . 3 1
a ga i n s t r a d i u s . 2 3 6
h ip. o r i g i n s o f . 2 6 2 of viscera l origin, 3 5 9
renection-in -actio n .
Sacro i l iac j o i o ts
self-bracing mec h a ni s m . restora tion
Referred pain
modilled S o m a tic Perception
Inven tory. 7 9 . 3 4 1 . 3 4 2 . 3 4 7 .
a n ky l o s i n g spondylitis. 5 8 . 59
disorder. 3 5 4
347.
Questionna ire. 79. 3 4 8
low back a n d coccygea l p a i n . c h r o n i c ,
192
mod i fied Ro l a nd M o r r i s Disabi l i ty
modified Z u n g Depression
cerv ical spine cord symptoms. groin pain . elderly wo ma n . 3 1 4 . 3 2 4
Oswes t ry Q u es t i o n n a i re. 5 3 . 5 9-60
348. 3 50
s
fear avoida nce and p hysica l
i n terpretation or. 3 4 1 - 3 4 2
Question n a ire. 3 4 1 . 3 4 2 .
o f fo rearm symptoms, 3 7 1-3 7 2 .
60
97 see also Home exerci se progra m m e S e l r-reflection . critica l . 1 0 S e l f-reflection wo rkshee t . 4 1 3 . 4 2 1 -4 2 2 S e l f-repor t i n g for m s . 3 4 1
p a i n source. shou lder p a i n . b i l a teral .
i nserti on i n to ster n u m . 3 74
3 72-3 7 3
swim mer. 1 7 2 te n n is e l b ow. 9 6 .
d y n a mic relocation test. 1 6 7
stretc h i n g on gym b a l l . reprod uction
Red nags. 8 . 1 8 .
s h o u lder p a in . bil atera l . l o ng-d istance
m od i fied
activation . d y n a m ic re l o c a t i o n
role i n reaso n i n g . 7
a n k l e spra i n . 1 2 8 cra n ioverteb ral dysfunction fo l l o w i n g
198
w i t h meta l f1x a t i o n . m o b i l i zatio n .
1 58
S e l f-d irected lear n i n g . 3 9 0 . 3 9 3 . 4 1 1
becom i n g . 2 2 7. 2 2 8
238
and h o l d i n g
1 6 3-1 6 5 Side-ly i n g tests. move m e n t im pairme n t
capacity headache, 1 3 8
syndromes . 2 64 . 2 6 5-2 6 6 . 2 6 7 .
'setti n g exercise ' . 1 4 1 .
143 . 144
Schober method . l u m ba r s p i n e . r a n ge of motion method .
344. 3 4 8
S c h o n . professional practice. 3 9 5
268 S i m u l a ted p a tients , 4 1 4 S ingle modal i ty approaches. peripar t u m pelvic pa i n , 3 2 7- 3 2 8 Si tting position. low back and l e g p a i n .
Sciatic nerve neuromobil ization exercises. 1 2 9
subacnte. 2 0 8 S i t t i n g tests
s tretch tes t. 2 8 1 Scott, c l inical reaso n i n g errors . 4 0 7 . 4 0 8
back and bil a tera l l e g p a i n . 2 9 - 3 0
Segme n t a l s p i n a l stabilizers
movemen t impairme n t syndromes.
i s o l a t io n . using neuromuscular s t i m u l a tion.
157
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2 66, 269 S i tu a te d l ea r ni n g . 3 8 3
""
I N DEX
Skin mobility. forearm pa i n preve n ting leisure activities. 3 6 6 . 3 6 7 S l eep position forearm pain preven ting leisure activities, 3 6 1 . 3 6 3 low back pai n , a c u te o n chro n ic, 3 4 2 , 346
S leepi ng patter ns. l o w back pa i n , acute on chron ic, 3 4 2 Slump test groin pai n , el derly wo man, 3 2 3 , 3 2 4 low b a c k p a i n , a c u t e on chron ic, 3 4 5 low back pain with sciatica, 2 8 1 t horacic pain l i miting activity, 1 5 3 , 155, 157
Social i n teraction w i th patients, medical exercise therapy, 2 8 7-2 8 8 Social responsibility, 3 8 5-3 8 6 S p i n a l c a n a l sou rce o f symptoms. groin pa i n , e l derly woman, 3 2 2 Spinal segment. FRS, 3 0 . 3 2 S p i n a l stab i l i ty and i n stability, 2 9 5 -2 9 6 low back and coccygeal p a i n . chronic, 1 06 , 1 09-1 1 0 , 1 1 6 med ical exercise therapy, 293 . 3 0 1 . 302
Spine global mobility tests , 2 8 1 local segmental mobi l i ty tests, 2 8 1 mech a n ical positio n i n g of. low back pain with sciatica , 2 8 2 stabi l i l ization, medical exercise therapy, 2 9 3 , 3 0 2 , 3 0 4 see also Cervical spine: Lumbar spine: Thoracic spine S pondylolisthesis, 3 44 back a nd b i lateral leg pain , 3 1 low back pain , acute o n chronic, 3 4 5 , 346, 349
Spondylolysi s , l o w back pain , acute o n c h ronic, 3 4 5 Sports i nj u ries med ial collatera l ligament repair. professional ice hockey player. 1 8 0-1 9 3
patellofemoral pain, profess ion a l ten n i s player, 1 9 4-204 Spri n g i n g test. spinous processes, 2 8 2 S p u r l i n g test, lower back, 2 8 2 S tage theo ry, knowledge acquisition a nd deve lopment. 1 1 - 1 2 S t a n d i n g tests back a n d bilatera l leg pain. 2 9 l o w back pain. chronic. 5 5 movement impairment sy ndrom es. 2 64 . 2 6 7
S teroid i njections, l u m ba r zyga pophyseal j o i n ts groin p ai n , elderly woma n . 3 2 1 S tra ight leg ra ise a n kle spra i n , 1 2 6 groin pain , elderly woma n , 3 1 5 low back pain. , a c u te on chron ic. 3 4 4 , 349
l o w back p a i n w i t h sciatica. 2 8 1 movement i m p a irme n t syn dromes, 2 6 5 . 2 6 7-2 6 8
n o n-musculoskeleta l d isorder appearing a s musculoskeletal d isorder. 3 5 5 peripartum pe l v ic p a i n , cl1[onie. 3 2 8 . 330 val idity of active. 3 3 0 Stress b i t i n g pa rafu nctio n a l hil b its. 2 4 4 central pain states, 1 5 prolonged . 1 3 red uction . progressive rela xation exercises. 3 4 7 . 3 5 0 and somatic illness, 2 7 8 systemic response to. 1 6 . 1 8 7 S tr u ctural and fu ncti o n a l c h a n ges. symptoms. s o u rces of. 2 8 4 Studen t-centred lea r n i ng . 3 8 5 S u boccipital tri angle, pa l pa t i o n , 2 4 5 Su b ta l a r j o i n t mo b i liza t i o n , 2 0 3 sti ffness and s hock absorption. 1 9 9 S u p i ne exa m i n ation back a n d b i l a teral leg pai n . 30 movement i mpairment syndromes,
hip pai n . adolescen t . 2 6 2 -2 6 3 loc a l i Z i n g . 1 7 low back a nd coccygeal pai n , chron ic, 104, 1 1 0- 1 1 1
and leg p a i n . s u bacute. 2 0 7 leg a n d thorax trou bles with teo n i s elbow and headache. 3 7 p a in . chronic. 5 2 . 5 4 5 6 5 7 pain and sci a tica. medical exercise therapy, 2 8 3-2 84 mec h a n ic's el bow. 8 8 - 8 9 . 9 4-9 5 non-musculos keletal d i sorder appearing as muscu loske l e t a l disorder, 3 5 3 . 3 5 5 p a tellofemoral pain . professional tennis player. 1 9 6 . 1 9 8 - ] 9 9 shou lder pa i n , bil atera l . long d is t a nce swimmer. 1 6 4 . 1 6 8 - 1 6 9 thoracic pain l i m i t i n g acti v i ty. 1 5 1 Synov i a l membra ne. TMJ, 2 4 6 Synovial TMJ pa i n m a p e v a l uation.
, -
2 4 6- 2 4 8
Systems of body. i n ter-rel ation s h i ps of.
2 6 4-2 6 5 , 2 6 7-2 6 8
non-musculoskeletal d isorder a ppe ari ng as musculoskeleta I d isorder, 3 5 5 S u rgery. tissue dam age and cen tra l sens i tization, 3 5 9 Swiss ball work forearm pain preventing leisure activities. 3 7 1 -3 7 2 s houlder p a in . bilateral . long-distance swi mmer. 1 7 1 . 1 7 3 thoracic pain limiting activi ty. 1 5 7 , 1 58 Sympathetic nervous syste m n n kle sprai n , 1 2 6 . 1 3 0 impairment. heart disease. 3 6 2 p a i n st.ates, 1 6 Symptom behaviour a n d pattern facial p a i n . chron ic. 244 forearm pain preventing leisure activities. 3 6 0-3 6 1 gro i n p a i n , elderly woma n . 3 1 4 low back pain with sc iatica. 2 7 6 . 2 7 7 . 280
thoracic p a i n limiting activi ty, 1 5 0 Symptom Check List 9 0 . psychopathology testi ng. 3 3 1 -3 3 2 Symptoms. sources of a nkle spra i n , 1 2 4- 1 2 5 back a n d bilateral leg p a i n . 2 8 , 3 1 cra n i overte b r a l dysfuDction following motor vehicle accident. 2 1 7-2 1 8 . 224
facial pain. chronic, 2 4 4 . 2 4 5-2 4 6 . 2 4 9 fear avoid ance a n d p hysical i ncapacity, u n necessary, 6 6 . 7 3 forearm pain preventing leis u re activ i ties. 3 6 8- 3 6 9 fractured radius w i th mental fLXation. 230. 233, 2 3 7
groin p a i n . eld erly wom a n , 3 1 3 , 3 1 5 -3 1 6
headache, 1 3 6- 1 3 7 . 1 40
Copyrighted Material
369
T Ta mpa Scale for K i n esiophobia. 3 3 1 Teac h i n g , 9 as art, craft and sci e n ce. 3 9 8 . 3 9 9 role o f in man u a l therapy, 2 0 . 4 9 . 1 6 5 Teach i n g a n d learn i n g programmes. goa l s o f. 3 8 3 -3 8 7 Temperature altered perceptio o , frac tured rad i u s wi th m e t a l fixation . 2 2 9 . 2 3 8 variatio n , a nkle s prain. 1 2 5 . 1 2 7 . 1 3 1 . 132
Temporom a n d i b u l a r j o i n t (TMJ) i n craniovertebral dysfu nction fo l lowin g motor veh icle accident, 216
disc s u b l u x a tion see Facial pa i n . chronic evaluatio n . 246- 24 8 l oc a l tissues a s pote n l i a l so urces for p a i n fu l . 2 4 5 -246 Temporomand i b u lar ligam e nt. 2 4 7 Ten n i s el bow. 9 2 l ocal structu res a s sou rce o f pa i n . 9 4 microtra u m a . 9 2 mobilizations w i t h movement ( MW M s ) , 9 3 -9 4 , 96. 98. 99. 1 00 m u scle imb a l a nce. prolongation by. 92
pathobiol ogy, 8 9 , 9 9 sel f- treatment. 9 6 . 97 ta p i n g . 9 6 see also Mec h a nic's elbow Tensor fasc i a lata, Thomas tes t , 1 9 6 . 1 9 7-1 9 8
Theraband. pre-tra i ning exerc ises, b i l a tera l s houlder p ai n i o long足 d i s t a nce swim mer. 1 7 1
I N DEX
Th e r a p e u ti c d y n a m ic ma gnetic resonance
252. 2 5 5 .
i m a g i ng.
259
streng t he n i n g . b i l atera l s h o u l d e r p a i n .
l on g
p roc ed ure . 2 4 9
test u n der. 2 5 1
systems. 2 3 3
.
go a l s
p a tel l o re mo r a l knee
1 5 4-1 5 6 su bjective exa m i n ati o n . 1 49- j 5 0
.
1 5 0- 1 ') 2 ch r o n ic 3 4 7
g ro i n
\"le i g h t
on
trial
break rrom . 3 2 0
.
m a n ll a l t h e r a py 3 2 0
p a r t or d i a g n o s t i c proces s . 1 4 7- 1 4 8
rorea r m p a i n preve n t i n g
l e i s u re
wo rseni n g symptoms. p a l e l l o i'e mora l
activities. 3 7 4
back. tho rax and leg tro ub l es w i th ten nis el bo w a nd headache. 4 2
tho r ac ic p a i n lim i ti n g activi ty. 1 5 2 .
k n ee p a i n . p r ore ss i o n a l te n n is
.
p l a ye r 1 9 6 T r u n k rotat i o n
b i o m e c h a n i c s p r o p o se d
in
-
m id t h o rax .
1 52. 1 53 . 1 54
1 5 3 . 1 54
Thoracic spi ne
exercises.
m ed i ca l
.
l e is u re
rractured r adi us w i th m e t a l lix a t i o n j o i n t f'i x a t i o n . 1 5 0
.
low back p a i n . a c u te on c hronic. 3 4 7 .
limiting acti v ity. ] 5 2 .
col l a tera l l i g a m e n t
Upper
limb
repair. 1 8 6
.
'
m us cu l oske le ta l
.
165.
Tra n s l a tory tra ction i n to resistance w i t h 235
Tra n s l atory vo l a r g l i d i ng o r s ca p h o i d against radi u s . 2 3 6
Tra n s vers u s a b d omi n i s a n a to my d i a g r a m . 1 07 contraction i n d ep e nd e nt or s u p erf'i c i a l muscles. 1 0 7 . 1 0 8 . 1 1 2 . 1 1 5 . 1 1 7 .
.
118
p a l p a tion tech n iq u e . d i a g r a m p o o r recru i tmen t . 3 2 9
y Yel l o w nags.
8 . 1 9 . 40. 42
Yoga. peripar t u m pelv i c p a i n . c hron ic.
9 . 20.
rorearm stabilized. :2 34.
mech a n i c ' s el bow. 9 2
disorder. 3 5 3-3 5 4 . 3 5 5
Tissu e mechanisms. path obiologica l . 1 5
3 3 5- 3 3 6
exa m i n a t i o n . 2 3 1
activities. 3 6 5 . 3 6 8
ap peari n g as
Train i n g a n d effi c i e n cy i n le a r n i n g
390
rractured ra d i u s w i th metal Hxa ti o n
U pper motor n e u r o n . n o n Â
Tissue h e a l ing. van den B e rg s model
Boud .
physica l ex a m in a t i on . 1 9 6-1 9 7 .
treatment. 2 3 5
m u s c u l os k el e t a l disorder
Transrorm a live l e a r n i n g
Wo r k i n g hyp o t h es is inn u e n cing
ne uro d y n a m ic testing.
fo rea r m pain p reve n t i n g l e i s u re
motor ve h i c l e
for. 2 3 4 . 2 3 7
prepara tion o r l ea r n e rs ror m . 3 9 6- 3 9 7 Work -based learning, 3 9 5-3 9 6
prepari n g learners for. 3 9 6-3 9 7
U I tTas o u n d . hea l i ng promotion. me dia l
359 accident. 2 1 7 . 2 1 8
2 3 9 . 240. 241
also B l a c k n a g s : B l u e nags Wo rk e n v iro n m e n t . 3 9 4-3 9 6 see
W r is t
1 53
Thyroid carc in o m a . rererred symptoms.
T i n n i t u s ro l l o w i n g
367
rractured rad i u s w i t h meta l lix a l i o n .
l e a rn i n g in. 3 9 5 -3 9 6
u
348 thoracic pain
fo re a rm p a i n preve n t i n g l e i s u re ÂŤclivi ties. 3 5 9 . 3 6 0- 3 6 1. 3 6 2 .
Workpl ace
a c ti vi ti es mobil ity tes ting. 3 64 2 40
Wo rk
224
symptoms. 1 2 9-1 3 0 forearm pain preventing
385
e v a lu a t i on . a n k l e
spra i n . 1 2 8 . 1 3 1 . 1 3 3
exercise therapy. 3 0 1
a n kl e s pra i n . tr e a t me nt r ed u cin g
be a r i n g
W i n d - u p . 3 7 ')
d e termi n i n g ap p r o p ri a tenes s o r
.'
' Ways or k now i n g .
a s pa r t or c o n t i n u o u s a ssess m e n t . 2 8 5
strate g i c use o r
a c u te
SCia tica . 2 7 6
mode.
pa i n e l d erl y woma n . 3 1 8
d i scussion a n d c o m m e n ta r y.
low
pa i n .
1 9 9- 2 0 0 as hy potheses te s ti n g
d i s c us s i o n and commen t a ry.
T hor a c ic r o ta ti o n
sciatica . 2 7 6 . 2 8 0 pa i n . p r o res s i o n a l ten n i s p l aye r. J 9 7 a n d symptoms. l ow back p a i n w i t h low b a c k p a i n wi th
pate l l oremora l k n ee
proress ional te n n is pl ayer.
p hy s ic a l exami nation . 1 5 2 - 1 5 3
back p a i n .
Wa l k i n g
b a c k a n d b il a teral l e g p a i n . 3 2
discussion a nd commentary. 1 5 8-1 59
o u t co me. 1 5 9
tests ror. 7 5 - 7 6 . 7 7 . 3 4 5
.
at fIT st ap poi nt m e n t 4 3 -44
Thoracic pa i n l i m i t i n g a c tiv i ty 1 4 9-1 5 9 m a n a geme n t . 1 5 6- 1 5 8
w Wa ddel l ' s S i g n s . 7 5 - 7 6 . 7 7
T re a t m e n t
II i 5
1 9 6 . 1 9 7- 1 9 8
.
swim mer. 1 7 0 108
p e r i p he r a l an d ce n t r a l nervous
exa m i n ation li n d i ng s . 2 5 0
Thoracic p a i n . l o w
d i s t a n ce
T r a u m a . pathobiological c h a n ges.
res u l ts . co r re l a t i o n to p h y s i c a l
Thomas test.
-
test for ind e p e n de n t activation .
rea ssess m e n t . 2 5 3 . 2 5 7 . 2 5 9
T h i n k i n g o n m u l tiple leve l s .
VL t a p i n g . i n h i b i tory. 2 0 2 . 203 VMO and VL t i m i n g . 2 0 1 - 2 0 2 . 2 0 2 . 2 0 3
109
exercises . 3 4 6
pretreatment a n d post-trea t m e n t .
red u cti o n
.
s pi na l s t a b i l i ty
256
""
.
336
v Va sc u l a r i nvo l vement. a n k le spra i n . 1 2 8- 1 2 9 as sessmen t . 1 2 6
.
causalgic-type p a i n p atter n 1 2 4 V ideo a n a lysis
Zung
ed ucation,
cervica l spine. headache. 1 3 8 . 1 3 9 . 1 4 1 c ar a c ci de n t. 2 2 0
41 4
Visceral i n p u t . thoracic segments. 3 6 6 .
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g r o i n p a in . e lder ly w o m a n . 3 1 6 . 3 1 8 l ow b a c k a n d
Visual A nalogue Scale p a i n score
peripartu m pelvic pai n . chr o n ic .
.
c ra n i ove r t e br a l dysfunction ro llow i n g
367
108
Inven tory. m o d i lie d
Zyga p o p by sea l j O i nt s
l u m b o pe l v i c rhy thm . 3 3 1 Videotapes.
D e p re s s i o n
7 9 . 3 4 1 . 3 4 2 . 3 4 7, 3 4 8 . 3 5 0
l u mbar spine a n d h i p . rorw a rd
b e n d i n g . 3 2 9- 3 3 0
z
coc cy gea l
chron ic. 1 1 0
332
pain.