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A process approach in manual and physical therapies: beyond the structural model

A process approach in manual and physical
therapies: beyond the structural model
Eyal Lederman*
CPDO Ltd., 15 Harberton Road, London N19 3JS, UK
Process Approach,
Structural Model,
Manual and Physical
CPDO Online Journal (2015), May, p1-18.
ABSTRACT A Process Approach is a current therapeutic model for manual and
physical therapists; in particular, in the area of musculoskeletal and pain care
(Lederman, 2013). A Process Approach promotes a view that the loci of recovery
and health are innate processes within the body/person, and are influenced by
the individual's environment (physical, psychological and social). The role of the
therapist is to co-create with the patient environments that support these self-
recovery processes. A Process Approach is a practical alternative to the tradi-
tional Structural Model in manual-physical therapies. It has important implications
for clinical and self-care management as well as treatment cost-effectiveness.
This approach also redefines the traditional therapist-patient roles in manual and
physical therapies. A Process Approach provides a potential new framework for
education and research in manual therapy.
There is a shared premise in manual and phys-
ical therapies that all individuals have a self-
healing capacity; and, that the viability of this
system determines the person's ability to
recover their health and functionality. It is also
assumed that recovery can be optimised by
removing particular obstacles that impede
self-healing (Mootz & Phillips, 1997; AACOM,
In manual and physical therapies the obstacles
to self-healing are often believed to arise from
faults, misalignments or imbalances within the
body's structure. By removing these structural
obstacles damaging stresses can be minimised
and physiology improved. When achieved, this
"utopian" structural state could help self-heal-
ing, prevent the development of pathology and
support well-being (Mootz & Phillips, 1997;
AACOM, 2015). This state could also reduce the
energy costs to the system; energy that can be
"utilised elsewhere" for self-healing. This ther-
apeutic approach is the basis of a Structural
Model in manual and physical therapies. This
model is frequently used to rationalise the
cause of the patient's complaint as well as to
justify the clinical management.
A Process Approach shares the view that the
body/person has the capacity for self-healing.
However, the focus in a Process Approach is to
identify the dominant processes associated
with recovery. Once identified, the aim is to
co-create with the patient environments that
support these innate recovery processes. This
is where a Process Approach takes a different
therapeutic vector from a Structural Model. In
a Process Approach the management is aimed
directly at supporting the recovery processes
rather than indirectly altering biomechanics/
structure/anatomy or posture, as proposed in
a Structural Model.
Why do we need a new clinical model?
The Structural Model is derived from 500 years
of anatomy and biomechanics in which the
body is viewed as a machine; and deeply influ-
enced by 20th century orthopaedics - the wish-
ful belief that permanent structural change
can be attained by knife-free "manual surgery",
e.g. correcting leg-length discrepancies, bal-
ancing muscle pairs, normalising spinal curves,
freeing and adjusting vertebra or joints, bal-
ancing the pelvis, influencing rib position,
rearranging the cranial bones or remodelling
fascia by manual means.
A process approach in manual and physical therapies: beyond the structural model
Research in the last two decades has eroded
the foundations of the Structural Model. It has
been demonstrated that perceived asymmetry,
imbalances or postural deviations are normal
biological variations and not pathology
(Lederman, 2011). Research in this field has
demonstrated that the cause of many common
musculoskeletal and pain complaints cannot
be explained by biomechanics, structure or
even posture (Bakker et al, 2009; Roffey et al,
2010; review, Lederman, 2011). This applies to
many of the conditions seen regularly in man-
ual and physical therapy practice. Included
are: acute and chronic low back and neck pain
(Dieck, 1985; Hamberg-van Reenen 2007;
review Lederman, 2011), shoulder conditions
such as impingement and frozen shoulder
(Zuckerman & Rokito, 2011), cuff tears
(Tashjian, 2012; Tashjian et al, 2014)
tendinopathies (Ackermann & Renström,
2012), pain conditions in the upper half of the
body including various periscapsular pain con-
ditions (Hamberg-van Reenen 2007; Waersted
et al, 2010) and various types of headaches
(Haldeman & Dagenais, 2001; Fernández-de-
las-Peñas et al, 2007; Fernández-de-Las-Peñas
et al, 2007). This implies that a structural
reorganisation/harmonisation of the body is
unlikely to be therapeutically beneficial in
managing these conditions.
There is also a practical limitation to a
Structural Approach. The assumed anatomical
changes brought about by manual means are
practically unattainable. The forces produced
by manual techniques and duration of expo-
sure to these physical challenges are far below
the threshold required for long-term adaptive
changes (see discussion, Lederman, 2013).
Tissues have loading-to-adaptation thresholds
which are often many times the force that can
be generated by manual techniques (Cyron &
Hutton, 1981; Chaudhry et al, 2008). Without
this loading-to-adaptation threshold our tis-
sues would progressively become lax by the
forces produced by muscle contractions and
the physiological stresses of daily activities
(Ramey & Williams, 1985; Nilsson &
Thorstensson, 1989). Furthermore, long-term
tissue and neural adaptation requires pro-
longed exposure to physical activities (Prosser,
1996; Harvey et al, 2000; Harvey et al, 2003;
Ben et al, 2005; Ben & Harvey, 2010). To
induce an adaptive tissue change, the manual
events would have to be repeated for many
hours daily, over several weeks or even months
(Bergmann et al, 2007; Arampatzis, 2010;
review, Lederman, 2013; Rohlmann et al,
2014). These time scales are unlikely to be
met in a clinical setting.
Even if we accept the argument that muscu-
loskeletal conditions can be improved by bio-
mechanical/structural change we would still
face the clinical hurdle of how to achieve it by
manual means. Here is where a Process
Approach provides a practical clinical alterna-
tive to the Structural Model.
The three recovery processes
As discussed above, a basic proposition in
manual therapies is that an improvement in
health is dependent on the person's innate,
self-healing / recovery processes. This raises
the question, what are these recovery process-
es and how do they differ from one condition
to another? For example, which process under-
lies recovery from acute injury, say an ankle
sprain, and how does it differ from the process
associated with recovery from a persistent
condition, such as chronic low back pain?
There are three principal processes through
Fig 1 : The three recovery processes. Recovery
from most musculoskeletal and pain conditions
is associated with one or several of these
Eyal Lederman
which a person can recover from any condi-
tion: repair, adaptation and alleviation of
symptoms (Fig. 1). If a person, say, sprained
their ankle or had surgery we would expect
them to recover their functionality through a
process of tissue repair (Witte & Barbul, 1997;
Mutsaers et al, 1997; Enoch & Leaper, 2008;
Bunker et al, 2014). On the other hand, if a
person was immobilised following an ankle
fracture we would expect dysfunctional tissue
and motor control adaptation to take place
(Kidd et al, 1992; Liepert et al, 1995; Muijka &
Padilla, 2001; Seki et al, 2001). Subsequently,
after removal of the cast, functional recovery
would be dependent on adaptive tissue
changes and central nervous system plasticity,
also an adaptive process (Kidd et al, 1992;
Tillman & Cummings, 1993; review, Lederman,
2005 & 2010). In this example, a functional
recovery is associated primarily with adaptive
In the next example a person is experiencing
chronic back pain for several months. Within a
few weeks of treatment there is a dramatic
improvement in their condition. Imagine that
a MRI scan was taken before treatment and
another several weeks later when the patient
is pain-free. Would we expect to see any tissue
changes that could explain the person's
improvement? The answer is probably not; the
spinal findings/pathologies are likely to
remain unchanged (Boos et al, 1995; van
Tulder et al, 1997; Savage et al, 1997;
Borenstein et al, 2001; Borenstein et al, 2001;
Waddell & Burton, 2001; Jarvik et al, 2005;
Carragee et al, 2006; Kanayama et al, 2009).
We can therefore assume that their recovery is
related to attenuation of their symptoms
rather than by tissue repair or adaptation
(Grubb, 2004; Woolf, 2011). Under these cir-
cumstances the patient would consider their
back condition to be fully recovered as they
are now able to carry out daily activities with-
out pain. Hence, another form of recovery is
through symptomatic change. Probably this
course of recovery underlies the clinical suc-
cesses of many chronic musculoskeletal pain
conditions (Fig. 2).
Fig. 2 - Recovery by alleviation of symptoms. This patient has extensive glenohumeral (GH) joint
pathology including complete rupture of GH capsule and tears of supraspinatous and long head of
biceps (A). Despite this extensive pathology and after six weeks of rupturing his biceps tendon the
patient was pain free and returned to playing tennis. Three years after the injury he is still playing
tennis regularly, without any shoulder pain (With permission from the patient).
A process approach in manual and physical therapies: beyond the structural model
The recovery processes in many conditions can
be readily identified. Acute injuries and post-
surgery conditions are associated with tissue
damage. Therefore, repair is likely to be the
principal recovery process, particularly in the
first 1-3 weeks after onset; depending on tis-
sue involved and extent of damage (Eming et
al, 2007). This includes conditions such as
acute spinal and disc injuries, joint / capsular-
ligamentous damage, muscle tears, etc. (see
review, Lederman, 2005).
Recovery by adaptation is associated with
chronic conditions where movement losses are
due to tissue and motor control changes.
Included are post-immobilisation conditions,
long-term contractures after injury or surgery
(see review, Lederman, 2005), stiff phase of
frozen shoulder (Neer et al, 1992; Uhthoff &
Boileau, 2007), as well as central nervous sys-
tem damage such as stroke (Johansson &
Belichenko, 2002; Molteni et al, 2004). Change
in movement patterns and use of posture are
also expected to be associated with adaptive
neuromuscular processes (Schmidt & Lee,
2005; review, Lederman, 2010).
A change in symptoms may play an important
role in recovery in a wide range of chronic con-
ditions; included are: improvement in low
back and neck pain (Boos et al, 1995; Jarvik et
al, 2005; van Tulder et al, 1997; Borenstein et
al, 2001; Waddell & Burton, 2001; Savage et al,
1997; Borenstein et al, 2001; Kanayama et al,
2009), symptomatic relief in osteoarthritis
(Staud, 2011; Lee et al, 2011; Murphy, 2012),
improvements in painful tendinopathies
(Alfredson & Lorentzon, 2002; Khan, 2003; Rio,
2014) and other unexplained local and region-
al whiplash-associated pain conditions
(Koelbaek-Johansen, 1999; Stone, 2013).
It should be noted that symptomatic recovery
is not limited to pain experience. It includes
other symptoms of 'dis-ease', such as stiffness,
paraesthesia and experiences such as anxiety
and depression.
Overlapping processes
In many conditions recuperation is associated
with a combination of recovery processes. This
is depicted by the overlap areas in Fig. 1.
The overlap between repair and adaptation
represents the recovery associated with
remodelling of tissues after injury. Initially,
repair is dominated by an inflammatory/
immune response that in time shifts towards
regeneration and later remodelling processes
(Eming et al, 2007). These latter processes are
largely adaptive in nature, influenced by the
individual's activities (Järvinen & Lehto, 1975;
Järvinen, 1976 & 1993; Goldspink, 1985;
Montgomery, 1989; Kiviranta et al, 1994;
Buckwalter, 1996; Vanwanseele et al, 2002;
Vanwanseele et al, 2002; McNulty & Guilak,
2015). This overlap also demonstrates the pos-
sibility for dominant recovery processes to
change over time; in this example, from repair
to adaptation (Fig. 3).
The overlap between repair and alleviation of
symptoms is often seen in recovery from acute
conditions. This recovery is partly by resolu-
tion of inflammation and attenuation of noci-
ceptive excitation at the site of damage. Some
of the symptomatic improvement is associated
with diminishing central sensitisation and a
parallel attenuation of allodynia and hyperal-
gesia in local tissues (damaged and undam-
aged, Woolf, 2011).
The recovery associated with alleviation of
chronic pain is represented by the overlap
between alleviation of symptoms and adapta-
tion. Often chronic pain is associated with
central sensitisation, a process related to neu-
ral plasticity and adaptation (Woolf, 2011).
Fig. 3 - Transformation and overlap of processes
from repair to adaptation
Eyal Lederman
This overlap is seen in conditions such as
chronic spinal pain, postoperative pain or
regional pain syndromes. Recovery in these
conditions is likely to be due to long-term
desensitisation; a process also associated with
neuroplasticity (Woolf, 2011).
In clinical reality, several of these processes
overlap in any given condition. However, often
one of these three processes tends to domi-
nate the person's process of recovery
(Figs. 4a, b & c).
Fig. 4b - Processes associated with functional recovery after immobilisation.
Fig. 4a - Processes associated with recovery in acute and chronic low back pain. The overlap between
alleviation of symptoms and adaptation represents CNS plasticity associated with recovery in chronic
A process approach in manual and physical therapies: beyond the structural model
Recovery environments and behaviour
The management in a Process Approach aims
to co-create with the patient environments
that will support their recovery. But how is this
management achieved; on what are these
recovery environments modelled?
To answer this we need to look back at the
self-healing proposition. When a person is
faced with the experience of injury, pain or
loss of functionality they tend to modify their
behaviour. The role of this specific behaviour is
to support the underlying physiological process
associated with recovery, e.g. reducing
weight-bearing activities (behaviour) on a
sprained ankle (tissue damage and inflamma-
tory process). This behaviour is part of a mul-
tidimensional protective/recovery strategy.
This whole person strategy is termed here the
recovery response and the behaviour associat-
ed with it the recovery behaviour. What
humans "do naturally" to recover functionality
seems to be well supported by rehabilitation
research and pain sciences (see above discus-
A Process Approach is informed by biopsy-
chosocial research and patient care is mod-
elled on the recovery behaviour. The manage-
ment revolves around identifying and amplify-
ing the behavioural traits that are beneficial to
recovery (Fig. 5).
Behaviour and repair environment
The recovery behaviour associated with repair
is marked by a short period of withdrawal from
physical activities that are potentially damag-
ing. This corresponds to the inflammatory
phase of repair when tissues are at their most
vulnerable state. This period is followed by a
regeneration and remodelling phase and is
matched by activities that gradually load the
affected areas; a behaviour that optimises
recovery of the tissues' physiological and bio-
mechanical properties. (Gelberman et al,
1980; Strickland & Glogovac, 1980; Gelberman
et al, 1982; Montgomery, 1989; Hargens &
Akeson, 1986; Akeson et al, 1987; Buckwalter
& Grodzinsky, 1999). This behaviour implies
that management of acute injuries could
include manual techniques that emulate this
physical environment, i.e. providing moderate
cyclical loading to the affected area. This can
be in the form of passive or active mobilisation
techniques or active movement challenges
gradually applied to the affected area.
This management modality can be applied to a
wide range of conditions including all post-sur-
gery care, connective tissue, muscle and joint
injuries, disc prolapse or any other acute con-
dition. However, within a short period from
onset (say, 2-3 weeks) the repair process
becomes more adaptive in nature suggesting a
shift towards an adaptive environment.
Fig. 4c - Processes associated with recovery in frozen shoulder.
Eyal Lederman
Behaviour and adaptation environment
Adaptive processes are profoundly influenced
by the recovery behaviour. Let's for a minute
imagine a condition such as ankle joint con-
tractures and range of movement limitation
following immobilisation in a plaster cast. In
the absence of medical care the individual will
attempt to execute activities which matter to
them most such as standing and walking. This
trait of carrying out movement which resem-
bles the intended activity is called task specif-
ic practice; or task rehabilitation when applied
as a therapeutic intervention (Lederman,
2010). Added to this, the person will gradually
increase the physical loading on that limb as
well as extend the time spent in these activi-
This recovery behaviour provides important
information about the nature of the adapta-
tion supporting environment. The management
strives to be active rather than passive. There
is strong evidence that active movement pro-
vides the necessary loading forces required for
tissue adaptation (Cyron & Hutton, 1981;
Chaudhry et al, 2008; Arampatzis, 2010).
Furthermore, motor control recovery is highly
dependent on active, task specific movement
(Goodbody & Wolpert, 1998; Van Peppen et al,
2004; Healy & Wohldmann, 2006; van de Port
et al, 2007; Bogey & Hornby, 2007; Sullivan et
al, 2007; Flansbjer et al, 2008; Cano-de-la-
Cuerda et al, 2015). Motor control science sug-
gests that movement should resemble daily
activities selected from the individual's move-
ment repertoire (Lederman, 2010 & 2013;
Cano-de-la-Cuerda et al, 2015). For example,
range losses due to ankle joint contracture
could be rehabilitated by daily activities that
challenge these movement losses, such as
walking, use of stairs, etc. However, move-
ment or manual techniques that are passive or
dissimilar to the individual's recuperation
objectives are generally less effective in sup-
porting functional recovery (Newham &
Lederman, 1997; Lederman, 2010 & 2013).
Fig. 5 - Management considerations in repair and adaptation processes.
A process approach in manual and physical therapies: beyond the structural model
Behaviour and alleviation of symptoms
The question that comes into mind here is
what actions do individuals take in order to
alleviate their pain / symptoms; and can this
behaviour be amplified as part of
manual/physical therapy management?
To explore pain modulating environments we
need to look at the nature of acute and chron-
ic pain. Often acute pain has a clear protective
biological role to prevent further tissue dam-
age. Chronic pain, on the other hand, has a
more obscure biological role, as underlying tis-
sue damage may not be evident or necessarily
the cause of pain (Niv & Dvor, 2004; Woolf,
2011). This suggests that in acute conditions
the therapeutic aim is to support repair (as
discussed above), rather than alleviating pain.
It would be expected that the pain experience
will attenuate in line with the resolution of
repair. Hence, the management in acute pain
conditions can follow the principles of "active
rest", i.e. mixing a period of rest with low
loading activities (see, behaviour and repair
environment above).
In chronic pain conditions, where pain has an
obscure role the management can focus
directly on pain alleviation and return to func-
tionality. Here, the symptom alleviating envi-
ronment is also modelled on the recovery
behaviour: maintaining daily activities, intro-
duction of progressive physical challenges
(overloading, repetition) and using the individ-
ual's own movement repertoire (specificity),
when possible. Concomitantly, providing sup-
port, reassurance and empowering information
plays a dominant role in management of per-
sistent symptoms (Garland, 2012; review,
Lederman, 2013; Nijs et al, 2013).
The role of manual therapy in alleviating
symptoms may be associated with touch
effects and "soothe-seeking" behaviour
(review, Lederman, 1998 & 2005). It has been
observed that when individuals are in distress
or pain they will often seek to alleviate these
experiences through social and physical con-
tact with others, e.g. touch (van der Kolk,
2002; Schweinhardt & Bushnell, 2010; Garland,
2012; Jaremka et al, 2014). This behaviour
contains psychological as well as physical com-
ponents that are partly "hard-wired" within
human behaviour and reinforced in childhood
through the parent-child relationship (Harlow,
1959 & 1961; Hooker, 1969; Burton & Heller,
1964; Morris, 1971; Reite, 1984; Schanberg et
al, 1984; Field et al, 1986; van der Kolk, 2002).
When a child (care-seeker) experiences pain
they will actively seek to soothe it by contact
with a significant other/parent (caregiver). In
response the parent will often use a soothing,
caring tone of voice and body manner that
invites closeness and contact with the child.
The child's anxieties are often soothed by cog-
nitive rational means ("you'll be alright; it's
only a small cut"). The parent / care-giver will
often make some form of physical contact with
the child, habitually lifting and rocking the
child or rubbing the painful area (Bowlby,
1969; Gordon & Foss, 1966; Korner & Thoman,
1972). Within this interaction empathy and
compassion play an important role in support-
Eyal Lederman
ing self-regulation and alleviation of symp-
toms. It is likely that this care-giving and care-
seeking is mirrored within the therapist-
patient relationship; where elements of this
interaction are amplified in clinic, Table 1
(Lederman, 1998 & 2005).
Multidimensional recovery environment
The management in a Process Approach aims
to co-create with the individual environments
in which recovery can be optimised. This envi-
ronment contains behavioural, psychological-
cognitive and social-cultural dimensions (Fig.
The recovery processes are heavily influenced
by the individual's physical-psychosocial envi-
ronment. These factors support the exposure
to beneficial movement challenges as well as
having important psychological influences.
These can have positive effect on well-being
and directly contribute to alleviation of symp-
toms (Smeets et al, 2006; Buchner et al, 2006;
Garland, 2012; Vachon et al, 2013; Jaremka et
al, 2014; Kamper et al, 2015). For example,
adaptation requires tissue loading and fre-
quent exposure to physical stresses. These
physiological needs can only be met when the
individual engages in activities that provide
such challenges. However, the individual's cog-
nitions about their condition, psychological
state and social-cultural factors may influence
their level of engagement in recovery behav-
iour (Bauman et al, 2012).
Imagine an individual who had a plaster cast
removed after ankle fracture. Their functional
recovery will be highly dependent on weight-
bearing activities such as walking and climbing
stairs. This behaviour, in turn, depends on cog-
nitive and psychological factors, motivation,
needs and functional goals ("get back to work,
be able to play tennis again", etc.). But this
recovery behaviour is also dependent on mul-
tiple environmental factors. They include
social (going out with friends), occupational
(walk to work), and recreational opportunities
(cycling, running).
Fig. 6 - Multidimensional management. The recovery processes are highly dependent on the actions
that a person takes within their environment. These factors need to be acknowledged and addressed
in the management. Adapted from LEDERMAN E 2013 THERAPEUTIC STRETCHING: TOWARDS A FUNC-
A process approach in manual and physical therapies: beyond the structural model
Obstacles to recovery
Back to the original premise that the person
has self-healing capacity; if that's the case why
do some individuals fail to recover their func-
Let us return to the example above of the
post-immobilisation patient. If the individual is
depressed, has fear of movement or re-injury
or lacks motivation they are less likely to
engage in recovery behaviour, say, going for
frequent walks (Kori et al, 1990; George et al,
2006; Elfving et al, 2007; Leeuw et al, 2007;
Thomas et al, 2008; Rainville et al, 2011).
Equally, other environmental factors can influ-
ence their recovery engagement. For example,
living in a small high-rise flat in a neighbour-
hood where stepping out for a walk is too dan-
gerous; or places where the climate does not
provide such opportunities (e.g. icy pavement
or intense heat). Hence, recovery and its
obstacles are multidimensional processes and
are addressed during the management (Table
In a Process Approach there is an emphasis on
exploring with the individual
opportunities/possibilities that could support
their recovery. The management also explores
the obstacles which may impede this process.
As discussed previously, these obstacles are
often complex bio-psychosocial processes and
rarely structural or postural.
Functioncise and self-care
There are 168 hours in a week. Most therapists
will see their patients once or twice a week.
This will provide a hands-on duration of, say,
30 minutes to an hour per week. So the ques-
tion is, where does the healing take place;
what happens in the 167 hours when we don't
see the patient?
Repair, adaptation and processes associated
with alleviation of symptoms are highly
dependent on frequent daily movement chal-
lenges, with some processes such as adapta-
tion requiring several hours per day of stimu-
lation (Kjaer et al, 2009). The weekly clinical
contact time with the patient or even the
addition of a structured exercise regime is
unlikely to meet these physiological demands.
It suggests that the clinical session provides
the initiation of management. However, what
the individual does within their environment
plays a crucial role in their improvement. But
in what activities should the patient engage
beyond the session?
The practical solution is to integrate the
movement challenges into the patient's envi-
ronment and daily activities. This form of
management is termed "Functioncise", where
particular daily activities are amplified to pro-
vide the movement challenges that support
the recovery processes. In this approach the
individual is encouraged to use their own
movement repertoire to recover their func-
tionality (Fig. 7).
Eyal Lederman
It is a "ready-made" therapy where movement
challenges are selected from activities that
are shared by the individual and others (walk,
stand, sit, etc), as well as from their unique
recreational or occupational movement reper-
toire. For a person who is recovering from a
knee injury and is unable to walk or climb
stairs, the management will be to challenge
walking gradually, and then stair-climbing,
etc. If they play tennis this activity will also be
incorporated later in the management (for full
discussion on this form of management see
Lederman, 2010 & 2014). Hence, in a Process
Approach the management is person centred
and highly individualised.
In contrast, a Structural management aims to
improve functionality by structural and biome-
chanical means, e.g. adjusting, balancing,
strengthening specific muscles, fixing, reposi-
tioning, realigning, resetting and postural and
movement correction. This is reflected in the
exercises by which these goals are pursued.
Structural orientated rehabilitation is mostly
extra-functional in nature; it contains move-
ment or activities that are outside the individ-
ual's experience. They include exercises which
are dissimilar to a recognisable functional
movement. These practices often promote
separation of movement from its goal focusing
on particular muscles, muscle groups or chains
(e.g. core exercise, scapular stabilisation and
muscle-by-muscle rehabilitation). Often move-
ment is fragmented into smaller components,
e.g. working specifically on knee extension
strength in sitting to improve walking.
Research suggests that such extra-functional
practices are not effective in improving func-
tional daily activities (Goodbody & Wolpert,
1998; Van Peppen et al, 2004; Healy &
Wohldmann, 2006; van de Port et al, 2007;
Bogey & Hornby, 2007; Sullivan et al, 2007;
Flansbjer et al, 2008; Cano-de-la-Cuerda et al,
2015; see reviews, Lederman, 2005, 2010 &
Engaging the individual in "functioncise" pro-
vides several important benefits. The patient
is using their own movement resources; what
they already know and recognise. They are not
required to learn new exercise regimes which
take time and effort, are often costly and
unachievable for most patients (e.g. learning
to contract specifically the core muscles). A
functional management seldom relies on any
specialized exercise equipment or set-aside
time for exercising. The remedial movement
challenges are integrated into the person's
daily activities; they can be practised any-
where and at any time. This approach uses the
patient's own recovery goals. It empowers
them to self-care and supports adherence to
the recovery programme (Ice, 1985; Sluijs et
al, 1993; Locke, 1966; Evenson & Fleury, 2000;
Jackson et al, 2005; Jolly et al, 2007; Chan et
al, 2009; Jordan et al, 2010; De Silva 2011;
Bauman et al, 2012).
Self-recovery: redefining the therapeutic
The capacity of the person for self-
healing/recovery suggests the need to re-
examine the traditional therapist-patient
roles. If individuals can self-heal, than what is
the therapist's role in this process?
In a structural approach the patient is highly
dependent on the therapist for removing the
structural obstacles to recovery, e.g. spinal
manipulation or cranial techniques. These
techniques cannot be self-administered. The
treatment table is often the centre-piece of a
structural treatment. This emphasises the
position of the patient as a passive recipient of
care. Under these therapeutic circumstances
the patient rarely achieves autonomy and the
locus of health remains permanently in the
hands of others.
A Process Approach provides the individual
with a different message. It promotes the view
that recovery lies fully within their body and
the actions they take (Chan et al, 2009). Most
of the clinical management by the therapist
can be replicated by the patient within their
environment. The patient is considered a
capable/valuable contributor to the manage-
ment, and is invited to take an active part in
their recovery. In a Process Approach the ther-
apist has the important role of health educa-
tor, as well as supporting and facilitating the
individual in their recovery process (Burton et
al, 1999; Linton & Andersson, 2000; Moseley et
al, 2004; McCall & Ginis, 2004; Henrotin et al,
2006; Nijs et al, 2013).
A process approach in manual and physical therapies: beyond the structural model
Role of manual therapy techniques in a
process approach
The role of hands-on, manual therapy is rede-
fined in a Process Approach. As discussed pre-
viously, in a Structural Model manual tech-
niques are often used to correct or remove an
obstacle in the structure. In a Process
Approach manual techniques are used to sup-
port the underlying recovery process.
In a Process Approach manual techniques are
viewed as a vehicle to deliver touch effects.
These can have a positive influence on sense of
self, well-being and body image (review,
Lederman, 1998 & 2005). Touch effects can
also have profound calming-soothing influ-
ences. Passive or active mobilisation of the
affected area by the therapist can provide
implicit reassurance that movement is safe.
Taken together, all these factors can support
recovery, particularly for alleviation of symp-
toms and pain.
Manual techniques (passive or active) that pro-
vide local or more general movement can be
used to support tissue repair processes. This
could be in situations when the patient is
unable to engage in recovery behaviour (often
due to pain or physical incapacity).
There is a clear message from research that
manual therapy techniques, in particular pas-
sive techniques, are likely to have little or no
effect on tissue adaptation or neuromuscu-
lar/motor plasticity (Lederman, 1997, 2010 &
2013; Kjaer et al, 2009; Tardioli et al, 2012). In
this area manual therapy can be used for guid-
ance or to support the active movement per-
formed by the patient. For full discussion and
demonstration of active management in clinic,
see Lederman, 2010.
In a Process Approach manual management can
be an important therapeutic tool. Fig. 5 and
Table 1 provide some suggestions about match-
ing the most suitable techniques/ manage-
ment to the individual's recovery process.
A clinical task
Next time you are with a patient ask yourself a
simple question: by which process is this per-
son likely to recover?
Some of the differences between a Structural
and a Process Approach are summarised in
Table 3.
Special thanks to Ian Stevens, Jennie
Longbottom, Rachel Fairweather, Dr. Pedro
Escudeiro and Rogerio Correa for their help
and support in writing this article.
The body / person has self-healing / self-
recovery capacity
The effectiveness of manual and physical
therapy depends on the person's self-recovery
A Structural Model holds the view that self-
recovery can be enhanced by removing struc-
tural/postural/ biomechanical obstacles
A Process Approach promotes the view that
the self-healing capacity can be supported
directly without the need to remove structur-
al obstacles
A Process Approach identifies three key
processes associated with recovery: repair,
adaptation and alleviation of symptoms
In a Process Approach the aim is to co-create
with the individual environments in which
their recovery process can be optimised
Self-care is a dominant component in a
Process management. The actions that an
individual takes within their environment are
seen as a key for recovery
All human activities provide physical chal-
lenges. Specific daily activities can provide
the movement challenges necessary for opti-
mal recovery. This approach where specific
activities are amplified is termed functioncise
Manual therapy can be useful as part of an
overall management. The role of manual
therapy is to support the patient's recovery
Eyal Lederman
Structural Model
Self-healing / recovery premise
Management focuses on creating ideal bio-
mechanical conditions for recovery
Manual techniques or physical activities aim
to correct structure or biomechanics
Medical diagnosis + biomechanical and
anatomical considerations
Tissue causing symptoms
Therapist or clinically determined manage-
ment goals
Structural change as therapeutic target
Management in the biomechanical dimension
Therapist dependent / external locus of
Pathologising normality (postural deviations,
asymmetries, imbalances, weak muscles,
Recovery occurs during the clinical sessions
Exercise dissimilar to human movement
Education - anatomy / biomechanics domi-
Process Approach
Self-healing / recovery premise
Management focuses directly on recovery
Manual techniques or physical activities sup-
port recovery processes
Medical diagnosis + by which process will
the individual improve
Identifying underlying recovery processes.
Tissue identification not essential for man-
Patient determined management goals
Patient determined functionality as thera-
peutic target
Multidimensional management
Emphasis on self-care / independence /
autonomy internal locus of health
Focus on pathways/opportunities to recov-
Positive messages and empowerment
Recovery occurs in individual's environment
Functional management created from the
patient's own movement repertoire
Education - processes directed
Table 3. Summary: comparison of Structural Mode to Process Approach. These are general principles.
They do not necessarily reflect the individual styles or views of therapists
A process approach in manual and physical therapies: beyond the structural model
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... An increasing body of evidence points to a biopsychosocial approach for musculoskeletal disorders as often the most appropriate when dealing with complex and fragile patients. This means that the role of the clinician is to manage the psychological aspects, reassure and educate the patient regarding their symptoms and prognosis in order to positively influence their coping strategies (Lederman, 2015;Nijs et al., 2015). Moreover, implementing Pain Neuroscience Education (PNE) into the multimodal treatment package helps in desensitizing the central nervous system (Lederman, 2015). ...
... This means that the role of the clinician is to manage the psychological aspects, reassure and educate the patient regarding their symptoms and prognosis in order to positively influence their coping strategies (Lederman, 2015;Nijs et al., 2015). Moreover, implementing Pain Neuroscience Education (PNE) into the multimodal treatment package helps in desensitizing the central nervous system (Lederman, 2015). Furthermore, explaining pain mechanisms in an understandable and patient-friendly manner as well as reducing fear avoidance behaviour before implementing work loads may increase the patient's ability to adhere to the management process (Lederman, 2015;Nijs et al 2013Nijs et al , 2015. ...
... Moreover, implementing Pain Neuroscience Education (PNE) into the multimodal treatment package helps in desensitizing the central nervous system (Lederman, 2015). Furthermore, explaining pain mechanisms in an understandable and patient-friendly manner as well as reducing fear avoidance behaviour before implementing work loads may increase the patient's ability to adhere to the management process (Lederman, 2015;Nijs et al 2013Nijs et al , 2015. Education strategies appear to have played an essential role in the management of this patient; for instance, the patient was concerned about the frailty of her bones and the risk of getting injured again which led to a psychological barrier whenever the patient moved her arm to perform exercises. ...
Background Proximal humerus fractures (PHFs) account for between 4% and 10% of all fractures in the elderly people and osteoporosis is frequently related to PHF. Furthermore, rotator cuff (RC) tears are also extremely common, affecting at least 10% of people aged over 60 in the United States. Among shoulder pathologies, the periarticular soft tissue disorders, including the RC, this is considered to be the most common. The incidence of full thickness RC tears increases with age. An aggressive surgical approach is often required for patients with massive RC tear and PHFs to restore the patients’ functional daily living activities. To the best of the authors’ knowledge, this is the first case report describing a successful conservative management in an elderly patient with a full thickness RC tear and PHF that refused surgery. Case Description This report describes the case of a 90-year-old woman with a massive RC tear who fell over on the sidewalk and sustained a PHF. The patient refused surgery even though it was recommended and prescribed by an orthopaedic surgeon. Intervention After having her shoulder immobilized with a brace as prescribed by the orthopaedic physician, the patient began a shoulder rehabilitation program with progressive work load exposure, functional movements and a pain and kinesiophobia education program. Outcomes After 3 and a half months, the patient achieved full recovery to her pre-injury level of function. Such outcome was assessed using the Numeric Pain Rating Scale (NPRS), the Disability of the Arm, Shoulder and Hand (DASH) scale, the Fear-Avoidance Beliefs Questionnaire (FABQ), the Pain Catastrophysing Scale (PCS), and the Global Rating of Change (GROC) scale. Discussion and Conclusion In an elderly patient with a massive RC tear and an undisplaced PHFs, patient education, pain reconceptualization and change of beliefs in combination with progressive work load exposure appeared to be an effective management strategy to achieve a return to the pre-injury level of function.
... Relief of pain should be a priority to build the patient's confidence and facilitate active engagement to optimise long-term outcomes. [50][51][52][53][54][55][56] In the second phase (time: 3 weeks; total: 9 visits; scheduling: 3 visits each week), the patient was instructed to perform an exercise programme following the physical therapist's instructions. Exercises were dosed and progressed according to pain levels and number of repetitions reached. ...
... This approach has enforced and improved his expectation for full recovery, which motivated him to strive towards a better outcome. [50][51][52][53] Pain education and exercise positively influenced the patient in terms of pain modulation. This case report encourages physical therapists to use biopsychosocially oriented treatments to obtain good outcomes and facilitate return to running in a patient with a thoracolumbar fracture that was ultimately stabilised with surgery. ...
... This case report encourages physical therapists to use biopsychosocially oriented treatments to obtain good outcomes and facilitate return to running in a patient with a thoracolumbar fracture that was ultimately stabilised with surgery. [50][51][52][53] In summary, this case report describes the clinical condition of a recreational runner presenting with post-traumatic thoracolumbar fracture, thus highlighting the importance of appropriate screening for physical therapists to facilitate the identification of potential pathologies that masquerade as a musculoskeletal condition by performing a thorough clinical examination. 31 patient's perspective I greatly appreciated the help and work of my physical therapist. ...
Running is one of the most popular sports worldwide. Studies suggest that 11%–85% of recreational runners have at least one running-related injury (RRI) each year, resulting in a reduction or interruption in training. A high risk for running-related injuries (RRIs) represents an important inconvenience counterbalancing the beneficial effects of running. RRIs primarily affect the joints of the lower limb and lumbar spine. Noteworthy, in some cases, the clinical presentation of signs and symptoms is confusing and may hide serious conditions; thus, clinicians have to pay special attention when potential factors arise, such as the presence of red flags. As reported in this case report, patients can present with low back pain (LBP) as a primary problem, mimicking a red flag such as a fracture of the spine. The aim of this case report was to describe a case of a recreational runner presenting with LBP as the sole symptom of an underlying thoracolumbar fracture.
... Riguardo, invece, al suo impiego associato a un modello di previsione multivariato (in cui la localizzazione viene aggiustata sulla base di età, peso, distanza vertex-marker) i dati disponibili oggi forniscono un'evidenza preliminare di accuratezza accettabile (66% 28 ). Evidenze preliminari riguardano l'utilizzo dell'angolo in- feriore della scapola come riferimento per l'individuazione del livello vertebrale T7 (scarsa accuratezza, 10% 26 ) e di un tenderness palpation 4,16,37 . Lo studio di Schneider et al 24 pur riportando, per tale metodica, valori di aidabilità di grado moderato-eccellente sia intra-sia inter-esaminato- re, non ne dimostra la superiorità clinica rispetto ad altre tecniche. ...
... La letteratura allo stato dell'arte non evidenzia diferenze statisticamente signiicative tra le varie metodiche palpa- torie indagate 4,16,37 . Nonostante il livello di evidenza non sia forte, l'aidabilità intra-esaminatore sembra avere un trend più coerente e di accettabilità clinica maggiore rispetto l'aidabilità inter- esaminatore e l'accuratezza. ...
... Trattamento e razionale L'esame clinico, così come la storia del paziente, sono en- trambi compatibili -come spesso accade -con almeno tre classiicazioni della ICHD 11 [35][36][37] . Inizialmente le mani- polazioni HVLA sono state eseguite limitatamente al seg- mento cervicale superiore C1-2 (Fig. 4), sebbene nelle ses- Lo sport era stato evitato per diversi anni, per timore che il dolore peggiorasse, inducendo forte apprensione anche in relazione all'abuso di FANS e alle possibili patologie correlate, contribuendo a incrementare il coinvolgimento emotivo del paziente e la presenza signiicativa di fattori psico-sociali. ...
Background: Cervicogenic headache is deined as chronic headache as the result of a dysfunction of the vertebrae, discs or soft tissue of the cervical spine commonly associated with neck pain. It is the third most common headache and is classiied as a “secondary headache” from the International Headache Society. he most Recent randomized controlled trials on the conservative treatment of this condition concluded that one of the most efective treatment option is High Velocity Low Amplitude thrust spinal manipulation. However, some carefully selected patients need surgery. his clinical case report describes the conservative management (i.e. manual therapy and musculoskeletal physiotherapy) of a patient with chronic cervicogenic headache, which still sufer of persistent symptoms, even after surgery. Case Presentation: a 36-years old male seeking treatment in a direct access setting, complaining of frequent headaches since eight years, with at least ive attacks a week in the last three months. In 2006, due to the failure of the pharmacological treatment, the patient underwent to his irst surgery. However, following the surgical intervention, the patient still complained of an occipital headache. After eleven months of pharmacological therapy, another surgical procedure was performed. However, after the second surgery procedure, patient still reported the same symptoms. Only later the patient was sent to a speciic conservative treatment with musculoskeletal physiotherapy and manual therapy. he patient received 9 treatment sessions. hen, the patient was evaluated at both 63-days follow up and at 180-days follow up from the last visit. Conclusions: he patient of this case showed a signiicant symptoms improvement. A better understanding of the pathophysiology, diagnosis and classiication of headaches would help in the best treatment option for this complex clinical condition. herefore, surgery should be considered as a second option if the conservative management fail in reducing headaches parameters. Manual therapy and musculoskeletal physiotherapy could be a valid alternative in the management of patients after surgery for chronic cervicogenic headache, in the absence of clear and deined postoperative therapeutic pathways. To our knowledge, this is the first case describing a manual therapy management after the failure of surgery for a patient suffering of chronic cervicogenic headache. KEYWORDS: Cervicogenic headache, high velocity low amplitude thrust, surgery,
... Recently, the mechanical view of human function has come under fire from various commentators within the world of manual therapies (Lederman, 2015(Lederman, , 2011Meakins, 2015). ...
... If the implication is, indeed, that mechanics are not statistically causative in injury or pain, then the more appropriate response is not to call for the eradication of biomechanical thinking, but to ask what, therefore, is missing within this equation? Lederman (2015) suggests that it has been demonstrated that asymmetries or altered spinal curves are normal variants and not pathologies. The word "normal" may have been picked wisely or coincidentally; as "normal" does not imply functional e nor optimal. ...
... A process approach Lederman (2015) has proposed what he terms a Process approach to working with patients. His views are somewhat dismissive of the biomechanical model, yet many are consistent with the broader approach espoused by Chek (2001) below. ...
... In our view, a more suitable word may be "Disorder" (Running Related Disorders -RRDs) that better describes multifactorial conditions which include, beside structural aspect, also psychosocial elements often present in nonspecific painful disorders like LBP [90][91][92][93]. ...
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Background: Running is one of the most popular sports worldwide. Despite low back pain (LBP) represents the most common musculoskeletal disorder in population and in sports, there is currently sparse evidence about prevalence, incidence and risk factors for LBP among runners. The aims of this systematic review were to investigate among runners: prevalence and incidence of LBP and specific risk factors for the onset of LBP. Methods: A systematic review has been conducted according to the guidelines of the PRISMA statement. The research was conducted in the following databases from their inception to 31st of July 2019: PubMed; CINAHL; Google Scholar; Ovid; PsycINFO; PSYNDEX; Embase; SPORTDiscus; Scientific Electronic Library Online; Cochrane Library and Web of Science. The checklists of The Joanna Briggs Institute Critical Appraisal tools were used to investigate the risk of bias of the included studies. Results: Nineteen studies were included and the interrater agreement for full-text selection was good (K = 0.78; 0.61-0.80 IC 95%). Overall, low values of prevalence (0.7-20.2%) and incidence (0.3-22%) of LBP among runners were reported. Most reported risk factors were: running for more than 6 years; body mass index > 24; higher physical height; not performing traditional aerobics activity weekly; restricted range of motion of hip flexion; difference between leg-length; poor hamstrings and back flexibility. Conclusions: Prevalence and incidence of LBP among runners are low compared to the others running related injuries and to general, or specific population of athletes. View the low level of incidence and prevalence of LBP, running could be interpreted as a protective factor against the onset of LBP. Systematic review registration: PROSPERO CRD42018102001.
... The resulting therapeutic benefits are now attributed to a broader 'complex interplay between neurophysiological effects, placebo, patient expectation, and therapeutic alliance' (Bialosky 2009). Within Lederman's (2015) 'Process Approach', MT is redefined as a 'vehicle to deliver touch effects' such as positive sense of sense and well-being' items which are reportedly lacking in many FM patients (Schleicher 2005). However there is no discussion in the literature regarding the length of time necessary for this interplay to reach a positive clinical outcome. ...
Background Current clinical guidelines do not support the use of manual therapy (MT) interventions for Fibromyalgia (FM) patients, despite evidence of positive biochemical, mechanical and psychological effects, and the popularity of hands-on treatments amongst patients. An optimal dose for MT has not been established; this may explain the discrepancies found within the published literature. The aim of this systematic review was to determine whether there is a dose response relationship for MT leading to improvements in core domains of FM symptomology; Pain, Mood, Sleep, Global Measure of Impact (Functional Status & Quality of Life). Methods We searched six databases from 1990 to January 2018; studies were evaluated using the PEDro scale. Within-group (ESd) and between-group (ESg) Effect Sizes were calculated. Results We identified and screened 4012 articles, 12 articles were critically appraised. Overall, there is moderate evidence that MT has positive effects on the four clinical outcomes investigated. However, there was no consistent dose response relationship observed across all studies. Conclusions A dose of approximately 45 minutes MT, three to five times per week, for three to five weeks, totalling 11 hours 15 mins, should be considered a baseline generic protocol for treatment delivery and research trials. Further research is necessary to confirm domain specific, or patient specific optimal doses. Moderator variables such as treatment time, frequency, duration; and MT type also need to be explored to ensure optimal delivery of MT in future research and clinical care provision.
... An increasing body of the literature suggests approaching musculoskeletal diseases from a biopsychosocial point of view. Under a psychosocial umbrella, PT should desensitize and, restore the patient's functional abilities [16]. For desensitizing the system and prior to starting treatment, in this case, the gap between the perceptions of the patient and the health care professionals concerning pain and its treatment should be narrowed [17], so we should start with pain education for explaining pain before loading the system. ...
Background: Shoulder pain is one of the most common problems affecting people older than 60 years. Among the shoulder pathologies, the disorders of the periarticular soft tissue (e.g. rotator cuff) are considered to be the most common; moreover, these disorders are found in approximately 75% of patients with seropositive rheumatoid arthritis. The incidence of structural rotator cuff tendon pathology, including full-thickness rotator cuff tendon tears, increases with age. Recent researchers suggested that non-operative treatment of full-thickness rotator cuff tears could be successful in some patients; furthermore, in rheumatoid arthritis patients, there was a greater possibility of developing surgical complications compared with non-rheumatoid arthritis patients. Materials and methods: A case report of a woman, 72 years old, with rheumatoid arthritis, shoulder pain and pseudo-paralytic arm presented with a massive tear of Supraspinatus and Infraspinatus tendon. In accordance with evidence, the case was managed using pain education and exercise therapy for 2.5 months. The shoulder pain, the function and the range of motion increased following a physiotherapy program. Conclusion: Pain education in combination with exercise therapy was effective for improving pain and function in a full-thickness tear of Supraspinatus and Infraspinatus tendon in a patient also suffering from rheumatoid arthritis.
... Historically, our understanding of the influence of contextual factors that affect outcomes in PT has been limited. This is evident as it shown that pain, especially persistent pain, behaves quite differently than previously understood (Louw and Puentedura, 2013), that LBP appears to be affected by social factors as much as physical pathology (Hill and Fritz, 2011), and that previously proposed biomechanical mechanisms of action for manual therapy may have been misguided (Bialosky et al, 2009;Jacobs and Silvernail, 2011;Lederman, 2015). Given the scope and number of recent revisions to our explanations for the therapeutic mechanisms of action, an outsider might wonder, "How much do they really know about what they are doing?" ...
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The successful practice of physical therapy requires a professional culture that places value on the interpersonal relationships that foster healing, and the face time required to build those relationships. Pressures on current practice are not facilitating this approach. The drive for increased productivity, cost effectiveness and ultimately, profit, are changing the landscape in which we practice. This phenomenon is fueled by an overemphasis on quantitative research in evidence-based medicine and an underappreciation of clinical expertise and patient values. This imbalance undermines the holistic, patient-centered approach that has been the basis for physical therapy since its inception. Authors suggest that in order to preserve defining characteristics of the profession, there is an urgent need to redirect our research agenda and PT education with a focus on the study of contextual and psychosocial factors that influence treatment outcomes. Recent research findings indicate that the effect of therapeutic alliance may be as important to outcomes as the chosen intervention. The authors suggest that excellence in Doctor of Physical Therapy (DPT) education must incorporate education addressing the vital importance of therapeutic alliance and also include training in the skills for developing such unique intentional relationships.
... Potentially, acute and chronic LBP may require different management strategies, since the underlying recovery processes of acute and chronic pain are likely to be different 45 . ...
Objectives: To assess the biomedical (BM) and biopsychosocial (BM) attitudes and beliefs of osteopaths towards the management of low back pain (LBP) and whether this is associated with certain demographic variables. Methods: A cross-sectional survey of UK osteopaths was undertaken utilising the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT), which assesses practitioners' treatment orientation (BPS or BM) in LBP management. A demographic questionnaire was used to assess the relationship with certain demographic variables. Results: Responses were analysed from 107 osteopaths. The mean PABS.PT score for the BM scale was 32.41 (SD 6.32) and 31.99 (SD 4.09) for the BPS scale. There was a statistically significant, negative correlation between the scales. Most osteopaths recognised stress as a contributing factor to LBP and believed in the benefits of exercise for LBP but had diverse views regarding the relationships between pain and tissue damage. None of the demographic variables were associated with the PABS.PT scales. Conclusion: Osteopaths' beliefs may indicate an acceptance of the BPS approach, but some still hold strong BM beliefs about pain, which may influence their clinical decision making. Future studies should investigate the impact of osteopaths’ beliefs on their clinical management of LBP.
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To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain. Systematic review and random effects meta-analysis of randomised controlled trials. Electronic searches of Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO, and CINAHL databases up to February 2014, supplemented by hand searching of reference lists and forward citation tracking of included trials. Trials published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by healthcare professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention. Forty one trials included a total of 6858 participants with a mean duration of pain of more than one year who often had failed previous treatment. Sixteen trials provided moderate quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.21, 95% confidence interval 0.04 to 0.37; equivalent to 0.5 points in a 10 point pain scale) and disability (0.23, 0.06 to 0.40; equivalent to 1.5 points in a 24 point Roland-Morris index) compared with usual care. Nineteen trials provided low quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.51, -0.01 to 1.04) and disability (0.68, 0.16 to 1.19) compared with physical treatments, but significant statistical heterogeneity across trials was present. Eight trials provided moderate quality evidence that multidisciplinary rehabilitation improves the odds of being at work one year after intervention (odds ratio 1.87, 95% confidence interval 1.39 to 2.53) compared with physical treatments. Seven trials provided moderate quality evidence that multidisciplinary rehabilitation does not improve the odds of being at work (odds ratio 1.04, 0.73 to 1.47) compared with usual care. Two trials that compared multidisciplinary rehabilitation with surgery found little difference in outcomes and an increased risk of adverse events with surgery. Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care. © Kamper et al 2015.
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Background A familial predisposition to the development of rotator cuff tearing has been previously reported. Very little information exists on the development of global tendon dysfunction in patients with rotator cuff tears. The purpose of the current study was to determine the incidence of global tendon dysfunction as well as the need for surgery for tendon dysfunction in patients with rotator cuff tears and their family members and compare them to age-matched controls. Methods Ninety two patients with full-thickness rotator cuff tears and 92 age-matched controls with no history of shoulder dysfunction or surgery responded to several questions regarding tendon diseases in themselves as well as their family members. Individuals were queried regarding the presence of tendon diseases other than the rotator cuff, the need for surgery on these other tendinopathies, the presence of family members having tendinopathies including rotator cuff disease, and the need for family members to have surgery for these problems. Chi-square analysis was performed to compare the incidences between cases and controls (P<0.05 was considered significant). Results The average age of patients in the rotator cuff tear group and control groups were 58.24±7.4 and 58.42±8.5 years, respectively (P=0.876). Results showed 32.3% of patients in the rotator cuff tear group reported that family members had a history of rotator cuff problems or surgery compared to only 18.3% of the controls (P=0.035), and 38.7% of patients in the rotator cuff tear group reported they had a history of other tendon problems compared to only 19.3% of individuals in the control group (P=0.005). Conclusion Individuals with rotator cuff tears report a higher incidence of family members having rotator cuff problems or surgery as well as a higher incidence of other tendinopathies compared to controls. This data further supports a familial predilection for the development of rotator cuff tearing and generalized tendinopathies.
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Tendon pain remains an enigma. Many clinical features are consistent with tissue disruption—the pain is localised, persistent and specifically associated with tendon loading, whereas others are not—investigations do not always match symptoms and painless tendons can be catastrophically degenerated. As such, the question ‘what causes a tendon to be painful?’ remains unanswered. Without a proper understanding of the mechanism behind tendon pain, it is no surprise that treatments are often ineffective. Tendon pain certainly serves to protect the area—this is a defining characteristic of pain—and there is often a plausible nociceptive contributor. However, the problem of tendon pain is that the relation between pain and evidence of tissue disruption is variable. The investigation into mechanisms for tendon pain should extend beyond local tissue changes and include peripheral and central mechanisms of nociception modulation. This review integrates recent discoveries in diverse fields such as histology, physiology and neuroscience with clinical insight to present a current state of the art in tendon pain. New hypotheses for this condition are proposed, which focus on the potential role of tenocytes, mechanosensitive and chemosensitive receptors, the role of ion channels in nociception and pain and central mechanisms associated with load and threat monitoring.</div
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In animal models, the impact of social and environmental manipulations on chronic pain have been investigated in short term studies where enrichment was implemented prior to or concurrently with the injury. The focus of this study was to evaluate the impact of environmental enrichment or impoverishment in mice three months after induction of chronic neuropathic pain. Thirty-four CD-1 seven to eight week-old male mice were used. Mice underwent surgery on the left leg under isoflurane anesthesia to induce the spared nerve injury model of neuropathic pain or sham condition. Mice were then randomly assigned to one of four groups: nerve injury with enriched environment (n = 9), nerve injury with impoverished environment (n = 8), sham surgery with enriched environment (n = 9), or sham surgery with impoverished environment (n = 8). The effects of environmental manipulations on mechanical (von Frey filaments) heat (hot plate) and cold (acetone test) cutaneous hypersensitivities, motor impairment (Rotarod), spontaneous exploratory behavior (open field test), anxiety-like behavior (elevated plus maze) and depression-like phenotype (tail suspension test) were assessed in neuropathic and control mice 1 and 2 months post-environmental change. Finally, the effect of the environment on spinal expression of the pro-nociceptive neuropeptides substance P and CGRP form the lumbar spinal cord collected at the end of the study was evaluated by tandem liquid chromatography mass spectrometry. Environmental enrichment attenuated nerve injury-induced hypersensitivity to mechanical and cold stimuli. In contrast, an impoverished environment exacerbated mechanical hypersensitivity. No antidepressant effects of enrichment were observed in animals with chronic neuropathic pain. Finally, environmental enrichment resulted lower SP and CGRP concentrations in neuropathic animals compared to impoverishment. These effects were all observed in animals that had been neuropathic for several months prior to intervention. These results suggest that environmental factors could play an important role in the rehabilitation of chronic pain patients well after the establishment of chronic pain. Enrichment is a potentially inexpensive, safe and easily implemented non-pharmacological intervention for the treatment of chronic pain.
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It is well established that the biomedical model falls short in explaining chronic musculoskeletal pain. Although many musculoskeletal therapists have moved on in their thinking and apply a broad biopsychosocial view with regard to chronic pain disorders, the majority of clinicians have received a biomedical-focused training/education. Such a biomedical training is likely to influence the therapists' attitudes and core beliefs toward chronic musculoskeletal pain. Therapists should be aware of the impact of their own attitudes and beliefs on the patient's attitudes and beliefs. As patient's attitudes and beliefs influence treatment adherence, musculoskeletal therapists should be aware that focusing on the biomedical model for chronic musculoskeletal pain is likely to result in poor compliance with evidence based treatment guidelines, less treatment adherence and a poorer treatment outcome. Here, we provide clinicians with a 5-step approach toward effective and evidence-based care for patients with chronic musculoskeletal pain. The starting point entails self-reflection: musculoskeletal therapists can easily self-assess their attitudes and beliefs regarding chronic musculoskeletal pain. Once the therapist holds evidence-based attitudes and beliefs regarding chronic musculoskeletal pain, assessing patients' attitudes and beliefs will be the natural next step. Such information can be integrated in the clinical reasoning process, which in turn results in individually-tailored treatment programs that specifically address the patients' attitudes and beliefs in order to improve treatment adherence and outcome.
Walking is one of the most important activities in daily life, and walking exposes the spine to a high number of loading cycles. Little is known about the spinal loads during walking. Telemeterized spinal implants can provide data about their loading during different activities. The aim of this study was to measure the loads on a vertebral body replacement (VBR) during level and staircase walking and to determine the effects of walking speed and using walking aids. Telemeterized VBRs were implanted in five patients suffering from compression fractures of the L1 or L3 lumbar vertebral body. The implant allows measurements of three force and three moment components. The resultant force on the VBR was measured during level and staircase walking, when walking on a treadmill at different speeds, and when using a wheeled invalid walker or crutches. On average, the resultant force on the VBR for level walking was 171% of the value for standing. This force value increased to 265% of the standing force when ascending stairs and to 225% when descending stairs. Walking speed had a strong effect on the implant force. Using a walker during ambulation on level ground reduced the force on the implant to 62% of standing forces, whereas using two crutches had only a minor effect. Walking causes much higher forces on the VBR than standing. A strong force reduction can be achieved by using a walker.
Although knowledge of the elements of the way trauma affects the mind and body is more than a century old, that body of knowledge has been gradually refined. Trauma is not primarily imprinted on people's consciousness but instead becomes deeply imbedded in people's sensate experiences. Talking and insight may help people regain a sense of mastery, but they are unlikely to change people's sensate experiences that form the engines of continuous traumatic reliving. The efficacy of eye movement desensitization and reprocessing (EMDR) as a therapy is relevant for the exploration of the basic underlying mechanisms of posttraumatic stress, such as how trauma affects subcortical processes of emotion regulation, arousal modulation, threat information, and memory processes. It promises to shed light on how the mind comes to integrate experience in a way that prepares it for future threats while distinguishing between what belongs in the present and what belongs in the past. Only careful observations, controlled experimentation, and their integration with the knowledge base of multiple other disciplines will allow us to fully appreciate the richness of this new method of psychotherapy that shows such promise to help people move beyond the tyranny of their traumatic histories. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Study Design: This was a prospective study of patients (study group) with symptomatic disc herniations and asymptomatic volunteers (control group) matched for age, sex, and work-related risk factors. Objective: To determine the prevalence of disc herniation in a matched group of asymptomatic volunteers and to access the diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Summary of Background Data: Disc herniations have been reported to occur in 20-36% of asymptomatic volunteers. A valid comparison of asymptomatic individuals and patients with disc herniations has not been performed. Methods: Forty-six patients with low back pain and sciatica severe enough to require a disceclomy were compared with 46 age-, sex-, and risk factor-matched (heavy lifting, twisting and bending, vibration, and sedentary activity) asymptomatic voluteers. Both groups had a complete clinical and magnetic resonance imaging examination and completed a questionnaire to assess differences in the psychosocial and work perception profiles. The prevalence and the severity of morphologic alterations (disc herniation, disc degeneration, and neural compromise) was analyzed by two independent radiologists in a blinded fashion. Differences between both groups regarding MRI findings, work perception (occupational mental stress, intensity of concentration, job satisfaction, and job-related resignation) and psychosocial factors (anxiety, depression, self-control, social support, and marital status) were compared using multivariate techniques. Stepwise discriminate analysis was used to identify the best discriminating variables within the magnetic resonance image, work perception, and psychosocial categories in terms of the diagnostic accuracy to predict group membership (study [pain] or control [no pain] group). Results: Matched controls had significantly more risk factors than a group of normal individuals. The present study has presented evidence that an age-, gender-, and occupational risk factors-matched group of asymptomatic patients shows a high incidence rate of disc herniations (76%). Although significantly less than the symptomatic group incidence of 96%, this represents a much higher prevalence rate than generally expected and reported in other studies of unmatched asymptomatic volunteers. Patients had more severe disc herniations (disc extrusions) than asymptomatic volunteers (35% vs. 13%). There was no significant differences regarding disc degeneration between both groups (96% vs. 85%). The only substantial morphologic difference between both groups was the presence of a neural compromise (83% vs. 22%), which was highly significant (P < 0.0001). There were significant differences between both groups regarding work perception (occupational mental stress, intensity of concentration, job satisfaction, and resignation; P<0.027) and psychosocial factors (anxiety, depression, self-control, marital status; P<0.0001). The best single predictor of a group membership was the extent of neural compromise. A combination of this factor with occupational mental stress, depression, and marital status was the best predictive model. With this model, the false-negative rate (potential overtreatment of disc morphology) was reduced by more than half compared with morphologic factors (nerve root compression) alone (22% vs. 11%). Conclusions. In an age-, sex-, and risk factormatched group of asymptomatic individuals, disc herniation had a substatially higher prevalence (76%) than previously reported in an unmatched group. Individuals with minor disc herniations (i.e., protrusion, contained discs) are at a very high risk that their magnetic resonance images are not a causal explanation of pain because a high rate of asymptomatic subjects (63%) had comparable morphologic findings. The only highly significant difference between the study group and control group regarding morphologic findings was the criteria of a nerve root compromise. Work perception and psychosocial factors were helpful in discriminating between symptomatic and asymptomatic disc herniations. (C) Lippincott-Raven Publishers.
Rotator cuff disease is the most common shoulder disorder treated by orthopedic surgeons. Little information exits regarding its prevalence and natural history. The prevalence of rotator cuff tearing increases with age as well as several other factors including smoking and family history. Knowledge regarding the natural history of nonoperatively treated tears as well as the healing potential after repair can be used to aid in refining surgical and nonsurgical indications for the treatment rotator cuff tears. An algorithmic approach to the treatment of rotator cuff tears is reviewed.