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

Full text

A process approach in manual and physical
therapies: beyond the structural model
Eyal Lederman*
CPDO Ltd., 15 Harberton Road, London N19 3JS, UK
KEYWORDS
Process Approach,
Structural Model,
Manual and Physical
Therapy
CPDO Online Journal (2015), May, p1-18. www.cpdo.net
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.
E-mail: cpd@cpdo.net
Introduction
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,
2015).
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
2
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
processes.

Eyal Lederman
3
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
processes.
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
4
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
5
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
LBP.

A process approach in manual and physical therapies: beyond the structural model
6
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-
sions).
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
7
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-
ties.
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
8
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
9
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.
6).
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-
TIONAL APPROACH. ELSEVIER

A process approach in manual and physical therapies: beyond the structural model
10
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-
tionality?
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
2).
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
11
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 &
2013).
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
relationship
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
12
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?
Summary
Some of the differences between a Structural
and a Process Approach are summarised in
Table 3.
Acknowledgments
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
capacity
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
processes

Eyal Lederman
13
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
health
Pathologising normality (postural deviations,
asymmetries, imbalances, weak muscles,
etc.)
Recovery occurs during the clinical sessions
Exercise dissimilar to human movement
(extra-functional)
Education - anatomy / biomechanics domi-
nated
Process Approach
Self-healing / recovery premise
Management focuses directly on recovery
processes
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-
agement
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-
ery.
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
14
References
AACOM 2015 What is Osteopathic Medicine". American
Association of Colleges of Osteopathic Medicine
(AACOM). Retrieved 10 March 2015.
http://www.aacom.org/become-a-doctor/about-
om#aboutom
Ackermann PW, Renström P 2012 Tendinopathy in sport.
Sports Health. May; 4(3):193-201.
Akeson WH, Amiel D, Woo SL-Y 1987 Physiology and thera-
peutic value of passive motion. In: Joint loading: Helminen
HJ, Kivaranka I, Tammi M (eds.) Biology and health of artic-
ular structures. John Wright, Bristol, 375-394.
Alfredson H, Lorentzon R 2002 Chronic tendon pain: no signs
of chemical inflammation but high concentrations of the neu-
rotransmitter glutamate. Implications for treatment? Current
Drug Targets. Feb; 3(1):43-54.
Arampatzis A, Peper A, Bierbaum S, Albracht K 2010
Plasticity of human Achilles tendon mechanical and morpho-
logical properties in response to cyclic strain. Journal of
Biomechanics. Dec 1; 43(16):3073-9.
Bakker EW, Verhagen AP, van Trijffel E et al 2009 Spinal
mechanical load as a risk factor for low back pain: a system-
atic review of prospective cohort studies. Spine (Phila Pa).
Apr 15; 34 (8): E281-93.
Baldwin KM, Haddad F 2002 Skeletal muscle plasticity: cel-
lular and molecular responses to altered physical activity par-
adigms. American Journal of Physical Medicine and
Rehabilitation 81(11 Suppl.):S40-51.
Bauman AE, Reis RS, Sallis JF, Wells JC, Loos RJF, Martin BW
2012 Correlates of physical activity: why are some people
physically active and others not? Lancet; 380: 258-71.
Ben M, Harvey LA 2010 Regular stretch does not increase
muscle extensibility: a randomized controlled trial.
Scandinavian Journal of Medicine and Science in Sports. Feb;
20(1):136-44.
Ben M, Harvey L, Denis S et al 2005 Does 12 weeks of regular
standing prevent loss of ankle mobility and bone mineral
density in people with recent spinal cord injuries? Australian
Journal of Physiotherapy. 51(4):251-6.
Bergmann G et al 2007 In vivo glenohumeral contact forces--
measurements in the first patient 7 months postoperatively.
Journal of Biomechanics. 40(10):2139-49.
Bogey R, Hornby GT 2007 Gait training strategies utilized in
poststroke rehabilitation: are we really making a difference?
Top Stroke Rehabilitation. Nov-Dec; 14(6):1-8.
Boos N, Rieder R, Schade V, Spratt KF, Semmer N, Aebi M
1995 Volvo Award in clinical sciences. The diagnostic accura-
cy of magnetic resonance imaging, work perception, and psy-
chosocial factors in identifying symptomatic disc herniations.
Spine (Phila Pa 1976). 1995 Dec 15; 20(24):2613-25.
Borenstein DG, O'Mara JW Jr, Boden SD et al 2001 The value
of magnetic resonance imaging of the lumbar spine to predict
low-back pain in asymptomatic subjects: a seven-year follow-
up study. Journal of Bone and Joint Surgery [American]. Sep;
83-A (9): 1306-11.
Bowlby J 1969 Attachment and loss. Hogarth Press, London.
Buchner M, Zahlten-Hinguranage A, Schiltenwolf M,
Neubauer E 2006 Therapy outcome after multidisciplinary
treatment for chronic neck and chronic low back pain: a
prospective clinical study in 365 patients. Scandinavian
Journal of Rheumatology. Sep-Oct; 35(5):363-7.
Buckwalter JA, Grodzinsky AJ 1999 Loading of healing bone,
fibrous tissue, and muscle: implications for orthopaedic prac-
tice. Journal of the American Academy of Orthopaedic
Surgeons. 7(5):291-9
Buckwalter JA 1996 Effects of early motion on healing of
musculoskeletal tissues. Hand Clinics. Feb; 12(1):13-24.
Bunker DL, Ilie V, Nicklin S 2014 Tendon to bone healing and
its implications for surgery. Muscles Ligaments Tendons
Journal. Nov 17; 4(3):343-50.
Burton AK, Waddell G, Tillotson KM et al 1999 Information
and advice to patients with back pain can have a positive
effect. A randomised controlled trial of a novel educational
booklet in primary care. Spine; 24: 2484-91.
Burton A, Heller L G 1964 The touching of the body.
Psychoanalytical Review. 51: 122-134.
Cano-de-la-Cuerda R et al 2015 Theories and control models
and motor learning: clinical applications in neuro-rehabilita-
tion. Neurologia. January - February; 30(1):32-41.
Carragee E et al 2006 Does Minor Trauma Cause Serious Low
Back Illness? Spine. 31(25):2942-2949.
Chan DK, Lonsdale C, Ho PY et al 2009 Patient motivation
and adherence to postsurgery rehabilitation exercise recom-
mendations: the influence of physiotherapists' autonomy-
supportive behaviors. Archives of Physical Medicine and
Rehabilitation. Dec; 90(12):1977-82.
Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T
2008 Three-dimensional mathematical model for deforma-
tion of human fasciae in manual therapy. Journal of the
American Osteopathic Association. Aug; 108(8):379-90.
Cyron BM, Hutton WC 1981 The tensile strength of the cap-
sular ligaments of the apophyseal joints. Journal of Anatomy.
January; 132(Pt. 1): 145-150.
De Silva D 2011 Evidence: helping people help themselves.
The Health Foundation publication. London
Dieck GS 1985 An epidemiologic study of the relationship
between postural asymmetry in the teen years and subse-
quent back and neck pain. Spine. Dec; 10(10):872-7.

Eyal Lederman
15
Elfving B, Andersson T, Grooten WJ 2007 Low levels of phys-
ical activity in back pain patients are associated with high lev-
els of fear. Physiotherapy Research International. 12, 1, 14-24.
Eming SA, Krieg T, Davidson JM 2007 Inflammation in
wound repair: molecular and cellular mechanisms. Journal of
Investigative Dermatology. Mar; 127(3):514-25.
Enoch S, Leaper DJ 2008 Basic science of wound healing.
Surgery (Oxford). Volume 26, Issue 2, February, Pages 31-37.
Evenson K, Fleury J 2000 Barriers to Outpatient Cardiac
Rehabilitation Participation and Adherence. Journal of
Cardiopulmonary Rehabilitation. 20(4):241-246.
Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML,
Pareja JA 2007 Neck mobility and forward head posture are
not related to headache parameters in chronic tension-type
headache. Cephalalgia. Feb; 27(2):158-64.
Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA 2007
Myofascial trigger points, neck mobility, and forward head
posture in episodic tension-type headache. Headache. May;
47(5):662-72.
Field TM et al 1986 Tactile/kinesthetic stimulation effect on
preterm neonates. Pediatrics. 77(5): 654-658.
Flansbjer UB, Miller M, Downham D et al 2008 Progressive
resistance training after stroke: effects on muscle strength,
muscle tone, gait performance and perceived participation.
Journal of Rehabilitation Medicine. Jan; 40(1):42-8.
Garland EL 2012 Pain Processing in the Human Nervous
System: A Selective Review of Nociceptive and Biobehavioral
Pathways. Primary Care. 2012 September; 39(3): 561-571.
Gelberman RH, Woo SL, Lothringer K, Akeson WH, Amiel D
1982 Effects of early intermittent passive mobilization on
healing canine flexor tendons. Journal of Hand Surgery
[American]. 7(2):170-5.
Gelberman RH, Menon J, Gonsalves M, Akeson W H 1980
The effects of mobilization on vascularisation of healing flex-
or tendons in dogs. Clinical Orthopaedics. 153:283-289.
George SZ, Wittmer VT, Fillingim RB, Robinson ME 2006
Fear-avoidance beliefs and temporal summation of evoked
thermal pain influence self-report of disability in patients
with chronic low back pain. Journal of Occupational
Rehabilitation. Mar; 16 (1): 95-108.
Goldspink G 1985 Malleability of the motor system: a com-
parative approach. Journal of Experimental Biology. 115,375-
391.
Goodbody SJ, Wolpert DM 1998 Temporal and amplitude
generalization in motor learning. Journal of
Neurophysiology. 79:1825-1838.
Gordon T, Foss BM 1966 The role of stimulation in the delay
of onset of crying in the newborn infant. Quarterly Journal of
Experimental Psychology. 18:79-81.
Grubb BD 2004 Activation of sensory neurons in the arthritic
joint. Novartis Foundation Symposium. 260:28-36.
Haldeman S, Dagenais S 2001 Cervicogenic headaches: a crit-
ical review. Spine Journal. Jan-Feb; 1(1):31-46.
Hamberg-van Reenen HH 2007 A systematic review of the
relation between physical capacity and future low back and
neck/shoulder pain. Pain. Jul; 130(1-2):93-107.
Hargens AR, Akeson WH 1986 Stress effects on tissue nutri-
tion and viability. In: Hargens AR (ed.) Tissue nutrition and
viability. Springer-Verlag, New York.
Harlow HF 1961 The development of affectional patterns in
infant monkeys. In: Foss BM (ed) Determinants of Infant
Behaviour. Methuen, London.
Harlow HF 1959 Love in infant monkey. Science. In
Physiological Psychology. Thompson RF (ed) WH Freeman,
San Francisco, p 78-84
Harvey LA, Batty J, Crosbie J et al 2000 A randomized trial
assessing the effects of 4 weeks of daily stretching on ankle
mobility in patients with spinal cord injuries. Archives of
Physical Medicine and Rehabilitation. Oct; 81(10):1340-7.
Harvey LA, Byak AJ, Ostrovskaya M et al 2003 Randomised
trial of the effects of four weeks of daily stretch on extensibil-
ity of hamstring muscles in people with spinal cord injuries.
Australian Journal of Physiotherapy. 49(3):176-81.
Healy AF, Wohldmann EL 2006 Specificity Effects in
Training and Transfer of Speeded Responses. Journal of
Experimental Psychology, Learning, Memory, and
Cognition, 32(3); 534-546.
Henrotin YE, Cedraschi C, Duplan B et al 2006 Information
and low back pain management: a systematic review. Spine
(Phila Pa 1976). May 15; 31(11):E326-34.
Hooker D 1969 The prenatal origin of behavior. Hafner,
London.
Ice R 1985 Long term compliance. Physical Therapy 65:1832-
9.
Jackson L, Leclerc J, Erskine Y, Linden W 2005 Getting the
most out of cardiac rehabilitation: a review of referral and
adherence predictors. Heart. 91:10-14.
Jaremka LM et al 2014 Pain, depression, and fatigue: loneli-
ness as a longitudinal risk factor. Health Psychology. Sep;
33(9):948-57.
Jarvik JG, Hollingworth W, Heagerty PJ et al 2005 Three-year
incidence of low back pain in an initially asymptomatic
cohort: clinical and imaging risk factors. Spine. 30: 1541-8.
Järvinen MJ, Lehto MU 1975 Healing of a crush injury in rat
striated muscle. 2. a histological study of the effect of early
mobilization and immobilization on the repair processes.
Acta Pathologica et Microbiologica Scandinavica. May
83(3):269-82.

A process approach in manual and physical therapies: beyond the structural model
16
Järvinen M 1976 Healing of a crush injury in rat striated mus-
cle. 4. Effect of early mobilization and immobilization on the
tensile properties of gastrocnemius muscle. Acta Chirurgica
Scandinavica.142(1):47-56.
Järvinen M 1993 The effects of early mobilisation and immo-
bilisation on the healing process following muscle injuries.
Sports Medicine. Feb; 15(2):78-89.
Johansson BB, Belichenko PV 2002 Neuronal plasticity and
dendritic spines: effect of environmental enrichment on intact
and post-ischemic rat brain. Journal of Cerebral Blood Flow
and Metabolism. 22, 89-96.
Jolly K et al 2007 The Birmingham Rehabilitation Uptake
Maximisation Study (BRUM). Home-based compared with
hospital-based cardiac rehabilitation in a multi-ethnic popu-
lation: cost-effectiveness and patient adherence. Health
Technology Assessment. Sep; 11(35):1-118.
Jordan JL, Holden MA, Mason EE, Foster NE 2010
Interventions to improve adherence to exercise for chronic
musculoskeletal pain in adults. Cochrane Database
Systematic Reviews. Jan 20; (1):CD005956.
Kamper SJ et al 2015 Multidisciplinary biopsychosocial reha-
bilitation for chronic low back pain: Cochrane systematic
review and meta-analysis. British Medical Journal. Feb 18;
350:h444.
Kanayama M, Togawa D, Takahashi C et al 2009 Cross-sec-
tional magnetic resonance imaging study of lumbar disc
degeneration in 200 healthy individuals. Journal of
Neurosurgery of the Spine. Oct; 11 (4): 501-7.
Khan KM et al 2003 Are ultrasound and magnetic resonance
imaging of value in assessment of Achilles tendon disorders?
A two year prospective study. British Journal of Sports
Medicine. Apr; 37(2):149-53.
Kidd G, Lawes N, Musa I 1992 Understanding neuromuscu-
lar plasticity: a basis for clinical rehabilitation. Edward
Arnold, London.
Kiviranta I et al 1994 Articular cartilage thickness and gly-
cosaminoglycan distribution in the young canine knee joint
after remobilization of the immobilized limb. Journal of
Orthopaedic Research. Mar; 12(2):161-7.
Kjaer M et al 2009 From mechanical loading to collagen syn-
thesis, structural changes and function in human tendon.
Scandinavian Journal of Medicine and Science in Sports. Aug;
19(4):500-10.
Koelbaek Johansen M, Graven-Nielsen T, Schou Olesen A,
Arendt-Nielsen L 1999 Generalised muscular hyperalgesia in
chronic whiplash syndrome. Pain. Nov; 83(2):229-34.
Kori S, Miller R, Todd D 1990 Kinesiophobia: a new view of
chronic pain behaviour. Pain Management. Jan/Feb: 35.
Korner A F, Thoman E B 1972 The relative efficacy of contact
and vestibular-proprioceptive stimulation in soothing
neonates. Child Development 43: 443-453.
Leeuw M et al 2007 The fear-avoidance model of muscu-
loskeletal pain: current state of scientific evidence. Journal of
Behavioral Medicine. Feb; 30 (1): 77-94.
Lederman E 1998 Fundamentals of manual therapy.
Churchill Livingstone, Edinburgh.
Lederman E 2005 The Science and Practice of Manual
Therapy. Elsevier, Edinburgh.
Lederman E 2010 Neuromuscular rehabilitation in manual
and physical therapy. Elsevier.
Lederman E 2011 The fall of the postural-structural-biome-
chanical model in manual and physical therapies: exempli-
fied by lower back pain. Journal of Bodywork and Movement
Therapies. Apr; 15(2):131-8.
Lederman E 2013 Therapeutic stretching: towards a function-
al approach. Elsevier.
Lee YC, Nassikas NJ, Clauw DJ 2011 The role of the central
nervous system in the generation and maintenance of chron-
ic pain in rheumatoid arthritis, osteoarthritis and fibromyal-
gia. Arthritis Research and Therapy. Apr 28; 13(2):211.
Liepert J, Tegenthoff M, Malin JP 1995 Changes of cortical
motor area size during immobilization.
Electroencephalography and Clinical Neurophysiology.
97:382-38.
Linton SJ, Andersson T 2000 Can chronic disability be pre-
vented? A randomized trial of a cognitive-behavior interven-
tion and two forms of information for patients with spinal
pain. Spine. Nov 1; 25 (21): 2825-31.
Locke EA 1966 Toward a theory of task motivation incen-
tives. Journal of Organizational Behavior and Human
Performance, 3, 157-189.
McCall LA, Ginis KAM 2004 The Effects of Message Framing
on Exercise Adherence and Health Beliefs Among Patients in
a Cardiac Rehabilitation Program. Journal of Applied
Biobehavioral Research 9(2): 122-135.
McNulty AL, Guilak F 2015 Mechanobiology of the menis-
cus. Journal of Biomechanics. Feb 9. pii: S0021-9290(15)00085-
8.
Molteni R, Zheng JQ, Ying Z et al 2004 Voluntary exercise
increases axonal regeneration from sensory neurons.
Proceedings - National Academy of Sciences U S A.
101(22):8473-8.
Montgomery RD 1989 Healing of muscle, ligaments, and ten-
dons. Seminars in Veterinary Medicine and Surgery: Small
Animal. 4(4):304-11.

Eyal Lederman
17
Mootz RD, Phillips RB 1997 "Chiropractic belief systems". In
Cherkin DC, Mootz RD (eds.). Chiropractic in the United
States: Training, Practice, and Research. Rockville, MD:
Agency for Health Care Policy and Research. pp. 9-16.
http://www.chiroweb.com/archives/ahcpr/uschiros.PDF.
Retrieved 10.3.15. AHCPR Pub No. 98-N002.
Morris D 1971 Intimate behaviour. Corgi, London.
Moseley GL, Nicholas MK, Hodges PW 2004 A randomized
controlled trial of intensive neurophysiology education in
chronic low back pain. Clinical Journal of Pain. Sep-Oct; 20
(5): 324-30.
Muijka M, Padilla S 2001 Muscular characteristics of detrain-
ing in humans. Medicine and Science in Sports and Exercise.
333:1297-1303.
Murphy SL, Phillips K, Williams DA, Clauw DJ 2012 The role
of the central nervous system in osteoarthritis pain and impli-
cations for rehabilitation. Current Rheumatology Reports.
Dec; 14(6):576-82.
Mutsaers SE, Bishop JE, McGrouther G, Laurent GJ 1997
Mechanisms of tissue repair: from wound healing to fibrosis.
International Journal of Biochemistry and Cell Biology. Jan;
29(1):5-17.
Neer CS 2nd, Satterlee CC, Dalsey RM, Flatow EL 1992 The
anatomy and potential effects of contracture of the coraco-
humeral ligament. Clinical Orthopaedics and Related
Research.280: 182-185.
Newham DJ, Lederman E 1997 Effect of manual therapy tech-
niques on the stretch reflex in normal human quadriceps.
Disability and Rehabilitation 19:8:326-331.
Nijs J, Roussel N, Paul van Wilgen C, Köke A, Smeets R 2013
Thinking beyond muscles and joints: therapists' and patients'
attitudes and beliefs regarding chronic musculoskeletal pain
are key to applying effective treatment. apy. Apr;18(2):96-102.
Nilsson J, Thorstensson A 1989 Ground reaction forces at dif-
ferent speeds of human walking and running. Acta
Physiologica Scandinavica. Jun; 136(2):217-27.
Niv M, Devor M 2004 Chronic pain as a disease in its own
right. Pain Practice. 4(3): 179-181.
Prosser R 1996 Splinting in the management of proximal inter-
phalangeal joint flexion contracture. Journal of Hand Therapy.
Oct-Dec; 9(4):378-86.
Rainville J, Smeets RJ, Bendix T et al 2011 Fear-avoidance
beliefs and pain avoidance in low back pain--translating
research into clinical practice. Spine Journal. Sep; 11 (9): 895-
903.
Ramey MR, Williams KR 1985 Ground Reaction Forces in the
Triple Jump. JAB. 1:3:233 - 239.Reite ML 1984 Touch, attach-
ment, and health - is there a relationship? In: Brown CC (ed)
The many faces of touch. Johnson & Johnson Baby Products
Company Pediatric Round Table Series, 10, p 58-65.
Rio E, Moseley L et al 2014 The pain of tendinopathy: physi-
ological or pathophysiological? Sports Medicine. Jan; 44(1):9-
23.
Roffey DM et al 2010 Causal assessment of awkward occupa-
tional postures and low back pain: results of a systematic
review. Spine Journal. 10: 89-99.
Rohlmann A et al 2014 Loads on a vertebral body replace-
ment during locomotion measured in vivo. Gait and Posture.
Feb; 39(2):750-5.
Savage RA et al 1997 The relationship between the magnetic
resonance imaging appearance of the lumbar spine and low
back pain, age and occupation in males. European Spine
Journal. 6 (2): 106-14.
Schanberg SM, Evoniuk G, Kuhn CM 1984 Tactile and nutri-
tional aspects of maternal care: specific regulators of neu-
roendocrine function and cellular development. Proceedings
of the Society for Experimental Biology and Medicine 175:
135-146.
Schmidt RA, Lee TD 2005 Motor control and learning. Fourth
Edition. Human Kinetics. UK.
Schweinhardt P, Bushnell MC 2010 Pain imaging in health
and disease--how far have we come? Journal of Clinical
Investigation. Nov 1; 120(11):3788-97.
Seki K, Taniguchi Y, Narusawa M 2001 Effects of joint immo-
bilization on firing rate modulation of human motor units.
Journal of Physiology. 530(3):507-519.
Sluijs EM, Kok GJ, van der Zee J 1993 Correlates of exercise
compliance in physical therapy. Physical Therapy. Nov;
73(11):771-82.
Smeets RJ, Vlaeyen JW, Kester AD et al 2006 Reduction of
pain catastrophizing mediates the outcome of both physical
and cognitive-behavioral treatment in chronic low back pain.
J Pain. Apr; 7 (4): 261-71.
Staud R 2011 Evidence for shared pain mechanisms in
osteoarthritis, low back pain, and fibromyalgia. Current
Rheumatology Rep. Dec; 13(6):513-20.
Stone AM, Vicenzino B, Lim EC, Sterling M 2013 Measures of
central hyperexcitability in chronic whiplash associated dis-
order--a systematic review and meta-analysis. Manual
Therapy. Apr; 18(2):111-7.
Strickland JW, Glogovac V 1980 Digital function following
flexor tendon repair in zone 2: a comparison of immobiliza-
tion and controlled passive motion techniques. Journal of
Hand Surgery. 5(6):537-543.
Sullivan KJ et al 2007 Effects of task-specific locomotor and
strength training in adults who were ambulatory after stroke:
results of the STEPS randomized clinical trial. Physical
Therapy. Dec; 87(12):1580-602; discussion 1603-7.

A process approach in manual and physical therapies: beyond the structural model
18
Tardioli A, Malliaras P, Maffulli N 2012 Immediate and short-
term effects of exercise on tendon structure: biochemical, bio-
mechanical and imaging responses. British Medical Bulletin.
Sep; 103(1):169-202.
Tashjian RZ 2012 Epidemiology, natural history, and indica-
tions for treatment of rotator cuff tears. Clinics in Sports
Medicine. Oct; 31(4):589-604.
Tashjian RZ, Saltzman EG, Granger EK, Hung M 2014
Incidence of familial tendon dysfunction in patients with full-
thickness rotator cuff tears. Open Access Journal of Sports
Medicine. May 27; 5:137-41.
Thomas JS, France CR, Lavender SA, Johnson MR 2008
Effects of fear of movement on spine velocity and accelera-
tion after recovery from low back pain. Spine (Phila Pa 1976).
Mar 1; 33 (5): 564.
Tillman LJ, Cummings GS 1993 Biology mechanisms of con-
nective tissue mutability. In: Currier D P, Nelson R M (eds.)
Dynamics of human biological tissue. F A Davies.
Philadelphia, Ch. 1, 1-44.
Uhthoff HK, Boileau P 2007 Primary frozen shoulder: global
capsular stiffness versus localized contracture. Clinical
Orthopaedics and Related Research. Mar; 456:79-84.
Vachon P et al 2013 Alleviation of chronic neuropathic pain
by environmental enrichment in mice well after the establish-
ment of chronic pain. Behavioral and Brain Functions. Jun 7;
9:22.
van de Port IG, Wood-Dauphinee S, Lindeman E et al 2007
Effects of exercise training programs on walking competency
after stroke: a systematic review. American Journal of
Physical Medicine and Rehabilitation. Nov; 86(11):935-51.
van der Kolk BA 2002 Beyond the talking cure: somatic expe-
rience and subcortical imprints in the treatment of trauma. In:
Francis Shapiro: EMDR, Promises for a paradigm shift. APA
Press, NY.
Van Peppen RP et al 2004 The impact of physical therapy on
functional outcomes after stroke: what's the evidence?
Clinical Rehabilitation. Dec; 18(8):833-62.
van Tulder MW, Assendelft WJ, Koes BW, Bouter LM 1997
Spinal radiographic findings and nonspecific low back pain.
A systematic review of observational studies. Spine (Phila Pa)
Feb 15; 22 (4): 427-34.
Vanwanseele B, Eckstein F, Knecht H, Stussi E, Spaepen A
2002 Knee cartilage of spinal cord-injured patients displays
progressive thinning in the absence of normal joint loading
and movement. Arthritis and Rheumatism. Aug; 46(8):2073-
8.
Waddell G, Burton AK 2001 Occupational health guidelines
for the management of low back pain at work: evidence
review. Occupational Medicine (London). Mar; 51 (2): 124-35.
Review.
Waersted M, Hanvold TN, Veiersted KB 2010 Computer
work and musculoskeletal disorders of the neck and upper
extremity: a systematic review. BMC Musculoskeletal
Disorders. Apr 29; 11:79.
Wai EK et al 2010 Causal assessment of occupational bending
or twisting and low back pain: results of a systematic review.
Spine Journal. 10: 76-88.
Witte MB, Barbul A 1997 General principles of wound heal-
ing. Surgical Clinics of North America. Jun; 77(3):509-28.
Woolf CJ 2011 Central sensitization: implications for the
diagnosis and treatment of pain. Pain. Mar; 152(3 Suppl.):S2-
15.
Zuckerman JD, Rokito A 2011 Frozen shoulder: a consensus
definition. Journal of Shoulder and Elbow Surgery. Mar;
20(2):322-5. Epub 2010 Nov 4.