Page 1

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BSc (Psych), PT, Grad Dip Advan Manip Ther, l'1AppSc

Senior Lecturer, Director, Master of Musculoskeletal and Sports Physiotherapy, Physiotherapy International Coordinator, School of Health Sciences, University of South Australia, South Australia, Australia AND

Darren A. Rivett

BAppSc (Phty), Grad Dip Manip Ther, MAppSc (Manip Phty), PhD

Associate Professor, Program Convenor and Head, Discipline of Physiotherapy, School of Health Sciences, Faculty of Health, T he University of Newcastle, New South Wales, Australia Foreword by

Lance Twomey BAppSc (WAIT), BSc (Hons), PhD (w.


Vice Chanceller, Curtis University of Technology, Perth, Australia














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BUTTERWORTH-HEINEMANN An imprint of Elsevier Science Limited

Š 2004. Elsevier Science Limited. All rights reserved. The rights of Mark Jones and Darren Rivett to be identified as authors of the Introduction. and Chapters J and 26 have been asserted by them in accordance with the Copyright. Designs and Patents Act J 988. All other chapters are copyright of Elsevier Science Limited. No part of this publication may be reproduced. stored in a retrieval system. or transmitted in any form or by any means. electronic. mechanical. photocopying. recording or otherwise. without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency. 90 Tottenham Court Road. London W J T 4LP. Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelphia. USA: phone: (+ J) 2J5 2387869. fax: (+ 1) 215 238 2239. e-mail: You may also complete your request on-line via the Elsevier Science homepage ( by selecting 'Customer Support" and then 'Obtaining Permissions'. First published 2004 ISBN 07506 39067 British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data

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Medical knowledge is constantly changing. Standard safety precautions must be followed. but as new research and clinical experience broaden our knowledge. changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose. the method and duration of administration. and contraindications. It is the responsibility of the practitioner. relying on experience and knowledge of the patient. to determine dosages and the best treatment for each individual patient. Neither the publbher nor the editors assume any liability for any injury and/or damage to persons or property arising from this publication. The Publisher

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List of contributors Foreword





Lance Twomey Preface



Ankle sprain in a 14-year-old girl

Gary Hunt








Diane Lee



Thoracic pain limiting a patient's secretarial work and sport

Principles of clinical reasoning in manual therapy 1 Introduction to clinical reasoning

Headache in a mature athlete

Gwendo/en Jull

lI搂U[.j路I' a

Chronic low back and coccygeal pain

Paul Hodges

Bilateral shoulder pain in a 16-year-old long-distance swimmer

Mark A. Jones and Darren A. Rivett


Mary Magarey



Clinical reasoning in action: case studies from expert manual therapists 25




tennis player


Jenny McConnell




Self-management guided by directional

Ongoing low back, leg and thorax

preference and centralization in a patient

troubles, with tennis elbow and

with low back and leg pain


Robin McKenzie and Helen Clare



Chronic low back pain over 13 years

Dick Erhard and Brian Egloff


Craniovertebral dysfunction following a motor vehicle accident



Er/ Pettman


Unnecessary fear avoidance and

A judge's fractured radius with metal

physical incapacity in a 55-year-old

fixation following an accident


Robert Pfund in collaboration with Freddy Kaltenborn


Louis Gifford


Patellofemoral pain in a professional

Back and bilateral leg pain in a 63-year-old

David Butler



.David Magee

Mark Bookhout


Medial collateral ligament repair in a professional ice hockey player

A chronic case of mechanic's elbow

Toby Hall and Brian Mulligan

m 87


A university student with chronic facial pain


Mariano Rocabado

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Adolescent hip pain



Shirley Sahrmann


A software programmer and sportsman with low back pain and sciatica


Theory and development



Chronic peripartum pelvic pain


john van der Meij, Andry Vleeming and jan Mens


Acute on chronic low back pain

A non-musculoskeletal disorder masquerading as a musculoskeletal disorder

Improving clinical reasoning in manual

Appendix 1: Reflective diary



Forearm pain preventing leisure activities


Appendix 2: Self-reflection worksheet

Peter E. Wells



Darren A. Rivett and Mark A. jones


Richard Walsh and Stanley Paris




Patricia Trott and Geoffrey Maitland



joy Higgs

An elderly woman 'trapped within her own home' by groin pain

Educational theory and principles related to learning clinical reasoning

Tom Arild Torstensen




Israel Zvulun

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List of contributors

J\1ark Bookhout

Joy Higgs

I''l'. MS

rhO. MHPEd. GradDipPhty, BSc

President. Physical Therapy Orthopaedic

Faculty of Health Sciences , University of Sydney,

Specialists, Inc, Minneapolis & Adjunct Associate

Sydney, Australia

Professor. Department of Physical Medicine and Rehabilitation, Michigan State University

Paul Hodges

College of Osteopathic Medicine. East Lansing.

Associate Professor. Department of Physiotherapy,

PhD. HPhly(Hons)

University of Queensland , Brisbane.

Michigan, USA

Australia David Butler


Gary Hunt

Director. Neuro Orthopaedic Institute and Lecturer. UniversiLy of South Australia,

Physical Therapy Program, Concord,

Adelaide, Austr<llia

Helen Clare

P'C DIY],. M/\. OCS. C['ed

Associate Professor. Franklin Pierce College New Hampshire; Senior Physical Therapist, Outpatient Physical Therapy Clinic, Cox Health

[,T, CrodDip,vlanipTher, MAppSc, DipMDeT

Systems, Springfield, Missouri. USA

fntern<ltional Director of Education, McKenzie fnstitute International. Wellington.

Mark A, Jones


BSc(Psych). PT. GradDipr\dvan,\llanipTher.


Brian Egloff

Senior Lecturer. Director. M aster of

MS. MP'!'

Musculoskeletal and Sports Physiotherapy,

Uniformed Services University. Bethesda

Physiotherapy International Coordinator,


School of Health Sciences,

Richard E, Erhard DC, P'l'

University of South Australia,

Assistant Professor, Department of Physical Therapy,

A delaide, Australia

University of Pittsburgh and Head of Physical Therapy and Chiropractic Services, University of

Gwendolen Jull

Pittsburgh Medical Centre, Pittsburgh, USA

Associate Professor, Department of Physiotherapy,

Louis Gifford


MPhty, PhD, F/\CP

University of Queensland. Brisbane . MAppSc,

SSe. Fesp

Private Practitioner, Falmouth Physiotherapy Clinic, Kestrel. Swanpool. Falmouth.

Freddy Kaltenborn

Cornwall, UK

Scheidegg. Germany

Toby Hall

Diane Lee

MSc. PostCradDipMaJlipl'hcr

Adjunct Senior Teaching Fellow, School of

PT. ProlUrhc(USA)


Clinical Director,

Physiotherapy, Curlin University of Technology.

Delta Orthopaedic Physiotherapy Clinic ,

Perth, Western Australia

Delta, BC. Canada

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Mary Magarey

DipTechPhysioGrad. DipAdvancedManipTherapy.

Shirley Sahrmann


Professor, Physical Therapy. Neurology.


Senior Lecturer, School of Health Sciences,

Cell Biology and Physiology, Director. Program in

University or South Australia, Adelaide, Australia

Movement Science and Associate Director. Program in Physical Therapy.

David Magee I:lPT. PhD

Washington University School of Medicine.

Professor, Department of Physical Therapy. Faculty of Rehabilitation Medicine, University of Alberta. Edmonton. AB, Canada

GeolTrey Maitland

Jenny McConnell

Tom Arild Torstensen

MBE. AlJA. FC SP. FACP. MAppSc(Hons)

Glenside, South Australia

I3AppSc. MbiorncclE

Patricia Trott

MSc(i1nal). GradlJipAdvManTher. filCP

Associate Professor, School of Health Sciences,


The Mckenzie Institute International. Waikanae, New Zealand

Jan Mens

BSc(Hons). PT.

CandS cienl( Advanced MSc)

Specialist in Manipulative Therapy MNFF, NorwelY

50G5, Australia

Mosman, NSW, Australia

Robin McKenzie

St. Louis. USA

University of South Australia, Adelaide, Australia

Lance Twomey

,"ID. PhD

BAppSc(WAll'). BSc(Hons). Phll(WAusl).


Department of Rehabilitation Medicine, Faculty of

Vice Chancellor. Curtis University of Technology.

Medicine and Health Sciences. Erasmus MC.

Perth, Australia

Rotterdam. The Netherlands

Brian Mulligan

John van der Meij PTMT

fNZSP(Hon). iJipMT

Private Practitioner and Lecturer. Wellington, New Zealand

Stanley Paris

Pain Science and Applied Neuro Science. School for Higher Education Leiden. Leiden.


President. University of Sl. Augustine. Florida, USA

Erl Pettman

PT. FCM"',],

Abbotsford. Be. Canada; Clinical Instructor.

Rotterdam. The Netherlands

Richard Walsh

Springs , Michigan. USA

OHSc. HSc(Med)(Hnns). DipPhys

Physiotherapy Demonstrator.

PT. OMT. MAppsc

Private Practitioner and Instructor for Orthopaedic Manuell Therapy, Physiotherapy Fetzer and Pfund. Kempten. Germany

Department of Anatomy and Structural Biology. University of Otago. Dunedin. New Zealand

Peter E. Wells

I3AppSc (Phly). GradDipManipTher.




Private Practitioner, Postgraduate Teacher.

MAppSc(ManipPhty). PhD

Associate Professor. Program Convenor and Head. Discipline of Physiotherapy. School of Health Sciences. Faculty of Health. The University or

The Physiotherapy Centre, Fulham, London. OK

Israel Zvulun

Newcastle. New South Wales. Australia

Mariano Rocabado


Clinical A natomist. Spine and Joint Center.

DSc PT Program at Andrews University, Berrien

Darren A. Rive tt

The Netherlands

Andry Vleeming

Owner, McCallum Physiotherapy Clinic .

Robert Pfund

Private Practitioner Manual Therapy and Clinical Consultant Trilemma. Senior Lecturer in


Private Practitioner and Clinical Consultant, Freelance Lecturer in Postgraduate Musculoskeletal


Full Professor. School of Dentistry.

Physiotherapy and Head of Clinical Education and

University of Chile and Director Physical Therapy

Research Unit, Rabin Medical Centre.

and Physical Medical Rehabilitation,

Golda Campus. Petah.

INTEGRAMEDICA, Santiago. Chile

Tikvah. Israel

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To place this book's emphasis appropriately on sound

responses. This approach to the treatment of joint pain

clinical reasoning within the framework of manual

and impalrment. along with an extensive repertoire

therapy, it is necessary to appreciate the evolution of

of sophisticated manual skills. remain at the very

mcll1ual therapy as a discipline in its own right. From

heart of manual therapy.

tentative beginnings. it has advanced significantly

Manual therapists are baSically problem solvers.

since the 196()s. Initially it focussed on skill acquisition

They are approached on a daily basis by individuals

and the careful but prescriptive application or passive

seeking assistance in the management of their body

movement techniques to vertebral and peripheral

pain or their activity/participation restrictions. There­

joints. The earliest courses in manual therapy con­

lore. contemporary therapists need not only excellent

centrated on joint structure, biomechanics, pathology.

skills in physical assessment and treatment but also

diagnosis and physical treatment in a mechanistic

first class communication and management skills.

way. seeking simple cause and effect relationships

They need also to understand legal and ethical issues,

between a patient's symptoms and signs and their

to be aware and have knowledge of potential behav­

physical treatment protocols.

ioural and psychological issues. to be prepared to

Present day manual therapy practice and education

work as part of a larger health-care Leam and to know

owes a great deal to the vision and efforts of individ­

when to refer patients on and involve other disciplines

uul pioneering therapists. A considerable body of work

within the team. Manual therapists have necessarily

has gradually been developed based on relevant litera­

become more holistic in their care, with a related

ture from the fields of orthodox medicine, osteopathy.

shift toward greater active management and patient

bone-setting and chiropractic. it has been further


promoted by personal contact between key interna­

Clinical reasoning is both collaborative and rel1ect­

tional practitioners. In addition, a substantial amount of

ive. The therapist works with the patient and with

work has been published. short courses have been

other disciplines as part of a health-care delivery model.

developed and tertiary programmes introduced.

Even manual therapists in sole practices need to be a

Manual therapy has been predominantly a highly

part of an extended multidisciplinary health network

individual and structured approach to patient exam­

if a patient is to be proVided with the most appropriate

ination and treatment by (largely passive) movement.

and timely treatment and advice, pertinent to their

Historically, it has rocussed on the carerul evaluation

particular clinical condition. This approach requires

and assessment of a patient. followed by the applica­

adequate time for retlection and consultation, so as to

tion of a specinc joint movement procedure and the

provide a reasoned and speci[1c response to the patient's

subsequent reassessment of the patient to evaluate


the success or otherwise of the procedure. Depending

Mark Jones and Darren Rivett have provided in

on the feedback. the therapist either continued with

this book an excellent overview of the issues central

more of the same manual procedure or else changed

to clinical reasoning in manual therapy and a wide­

to another technique. Such a method is truly patient

ranging selection of case studies from many parts of

centred given that the therapist's actions and treat­

the world. In addition, Joy Higgs has contributed a

ment protocol arc always guided by the patient's

key chapter on educational theory and principles

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relating to learning clinical reasoning. In this chapter

professionals are under closer examination than ever

readers are taken through the relevant educational

before, where patients demand both higher levels of

theory underpinning the teaching and learning (101'­

communication with their therapist and involvement

mal or self·directed) of clinical reasoning. ImportanLly,

in their own treatment. where the ethical relationship

this same theory will also assist practiSing clinicians in

between therapist and patient becomes a signilicant

their patient management. As Jones and Rivett point

factor, and where the likelihood of adverse publicity

out in Chapter 1. teaching is a fund,unental compon­

remains a potent force in the equation. Skilled clinical

ent or manual therapy treatment, yet manual therap­

reasoning will be critical to the clinician's ability to

ists traditionally have not received formal training in

practise autonomously yet collaboratively, lo generate

educalion/learning theory and the associaled teaching

und apply new knowledge and to continue their life­

slrategies. Finally, Jones and Rivett provide a chapter or

long learning.

practical suggestions on how readers can develop their

Manual therapy will only flourish as a viable discip­

clinical reasoning skills. To this end, the chapter links

line through the 21st century if it learns from good

the clinical reasoning theory aod the learning theory

basic and applied research and adapts appropriately to

from the earlier chapters <md encourages the reader to

the new knowledge available. The case study approach

apply this knowledge in assessing the provided case

to knowledge acquisition has always been an import­

studies and in their everyday clinical practice.

ant factor in professions as diverse as medicine, business

[n the past, manual therapy has relied as much on

and education. It is very pleasing to note the global

charismatic leadership as it has on objective evidence.

spread of the case studies in this volume and the ways

For the discipline to continue to progress in this new

in which they reinforce the basic tenets of clinical

millennium, it is essential for it to be based on strong

reasoning. This superb book takes the reader down

research, critical in its scrutiny or evidence provided

the path of knowledge and reflection to provide better

and reflective in the way in which the various treat­

treatment options for all.

ment hypotheses and protocols are introduced and evaluated. This will proceed in an environment where

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Lance Twomey


This book aims to promote the development of clinical

of quick-!1x techniques. but rather a self-help book

reasoning skills, thinking or decision-making skills,

for the motivated practitioner or student seeking to

in practitioners and students of manual therapy. For

progress along the road to clinical expertise by

the purposes of this book, we consider a manual ther­

improving their skills in clinical reasoning.

apist to be a health-care practitioner who regularly

The core of this book is the 23 detailed case reports

deals with the problems that are attributed to disorders

in Section 2, which have been contributed by renowned

of the neuromuscuJoskeletal system. The original pro­

and expert manual therapists from all over the world.

fessional training of the manual therapist. whether it

We would like to express our sincere gratitude to the

be in physiotherapy, chiropractic, osteopathy, medi­

case contributors, first for their enthusiasm for this

cine or another profession. is not important because

innovative project and, secondly and especially. lor

the clinical reasoning process is universal. As the term

their patience as the individual cases were developed

implies, manual therapists work to a large degree

and the associated clinical reasoning painstakingly

with their hands. although this should not be seen to

made explicit. Special thanks are also due to Professor

limit the role of the mallual therapist to techniques

Joy Higgs for her important and insightful contribu­

such as manipulation. mobilization or soft tissue pro­

tion with Chapter 2.5.

cedures. or to suggest that the patient's role is merely that of a passive reCipient of the therapist's healing

Finally, we wish to acknowledge the unwavering encouragement and support of Helen and Jannine.

hands. Indeed, manual therapists utilize a broad range

We hope that this book will be of value to manual

of hands-off physical and communicative (e.g. teach­

therapy clinicians. students and teachers and will

ing) management approaches, and all manual ther­

help to promote the role of clinical reasoning as the

apy practice requires active patient participation and

common loundation of all forms of manual therapy

collaborative decision making. Manual therapists are


now more than ever required to account for their clin­ ical decisions against a background of competing

M. A. Jones

demands such as evidence-based practice. funding

Adelaide, Australia, 2004

limitations, legal and ethical issues, and the informa­

D. A. Rivett

tion explosion in health care; this all makes an

Newcastle, Australia, 2004

increaSingly difficult task. As such, this is not a textbook

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Manual therapy expertise is multidimensional. incorp­

have very good logical thinking skills while lacking

orating a combination of innate and learned charac­

the creative and lateral thinking abilities required to

teristics including intellectual aptitude. personality

advance their profession.

(e.g. curiosity. empathy. humility). knowledge organi­

Closely associated with the content that is taught

zation. plus communication. manual and thinking

in our manual therapy courses are the beliefs we fos­

skills. Experts are often considered to be 'good thinkers',

ter. For example. many students and beginning prac­

but traditionally our academic and continuing educa­

titioners of manual therapy will adopt an allegiance

tion manual therapy programmes have given little

to a particular clinical approach. This in itself is prob­

formal attention specil1caUy to assessing and teaching

ably healthy. as a student who has acquired a system­

thinking skills. It is common for people to question the

atic approach to assessment and management is well

need to address thinking skills formally. since all of us

equipped to integrate additional philosophies and tech­

interpret. judge relevance. hypothesize. extrClpolate.

niques. providing the necessary open mindedness is

test hypotheses, prioritize, weigh evidence, draw con­

there at the outset. Unfortunately. however. political

clusions. devise Clrguments. plan. monitor the effects of

divisions between different manual therapy approaches .

our efforts. and engage in numerous other activities

and even within some approaches. have held many

that fall in the domClin of clinical reasoning anyway.

clinicians back from learning anything more than what

despite possibly never having received focussed instruc­

their own approach offers. Rel1ection is not openly

tion in thinking processes. However, this is not to

promoted and hence students and clinicians histor­

say that we do these things well in all circumstances

iC(:llly have not been encouraged to explore and chal­

or that we Clre unable to learn to do them better.

lenge their own beliefs.

It is often assumed that the thinking process will

Ret1ective scepticism means not taking for granted

students/clinicians Clcquire the necessary

any position. policy or justil1cation simply because it

knowledge base and practise applying this knowledge

h(:ls been presented by a source of authority. Many



in clinical situations. While this can be true and our

of our earlier beliefs. rules or strategies in manual

manual therapy programmes have obviously produced

therapy were formulated on the basis of empirical

many good thinkers. many poor thinkers have also

observations in the clinic and attempts to fit existing

come out of this traditional educational system. Weal<er

biomedic(:ll theory to those clinical observations. In

students and clinicians ol'ten lack key aspects of skilled

contrast. with the incre(:lsed focus on evidence-based

clinical reasoning . which limits their ability to acquire

practice. there (:lre growing pressures from both

knowledge through their education. or they acquire

within and outside the profession for greater account­

the knowledge but have great diffIculty in applying

ability (:lnd substantiation of clinical effIcacy. This.

this knowledge in a clinical context. Stronger students

combined with the push ror manual therapists to

and clinicians seem to possess good thinking skills

adopt the broader biopsychosocial model of health

already. so when equipped with further knowledge

and disability. has contributed to the current st(:lte of

they tend to excel. Or do they? Do we take our strong

manual ther(:lpy education. Contemporary manual

students and clinicians as far as they are capable?

therapy education. while acknowledging its roots.

And does this apply to you? Often an individual may

has moved forward to a biopsychosocial. reasoning


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and evidence-based system. Importantly, this evidence

of patient cases contributed by expert manual thera­

includes both propositional knowledge derived from

pists from around the globe. Experts were selected

research and well-tested. practice-generated profes­

based on their status in the manual therapy world, as

sional craft knowledge.

established through their clinical excellence. research.

The inl1uences of evidence-based practice. bio­

publications and teaching prol1le. An attempt was

psychosocial models of health. and clinical reasoning

made to have different 'approaches' of manual ther­

theory have provided an exciting btidge between dif­

apy represented, as well as a wide array of patient

ferent approaches to manual therapy. The clinical

problems from the more straightforward to the more


complex. Case contributors were simply requested to

reasoning process itself. as outlined in Chapter

should be fundamental to all approaches of manual

submit a real patient case, including their full exam­

therapy. Skilled clinical reasoning is essential for the

ination and management through to the point of

application of both research-based and experience­

closure. Following that, clinical reasoning questions

based evidence. As such. if all students and clinicians

were devised by the editors to extract each clinician's

could learn their respective approaches to manual

evolving thoughts throughout their own case. Our

therapy with specilk atlention to the cognitive skills

clinical reasoning commentary was then added with

of reasoning. including being reflectively critical of

the aim of highlighting examples of clinical reasoning

the assumptions thai underlie their own beliefs and

theory in practice. We have not attempted to critique

open minded to modification of their current views.

the clinicians' reasoning: rather we merely hope to

then the diversity within manual therapy could better

assist readers' understanding of clinical reasoning

contribute to advancement in the assessment and

theory by pointing out specilk examples as Lhey

management of patients' problems.

emerged through the unfolding cases reports.

While clinical reasoning has always been implic­

To maximize what can be gained from reviewing

itly taught in manual therapy education. it has only

these cases. our suggestion is to read through the case

1990s that clinical reasoning theory

and reasoning questions and attempt to formulate your

been since the

and learning activities have been more explicitly inte­

own answer before reading the clinician's answer.

grated into manual therapy curricula. The text by

Most questions relate to hypotheses formulated on

(2000: Clinical Reasoning in the

the basis of the information presented to that point.

Health Professions). now in its second edition. has pro­

Occasionally. clinicians are asked to extrapolate on

Higgs and Jones

vided health science educators with a rich resource of

their own philosophy or specific assessment and man­

clinical reasoning theory linked to education theory.

agement procedures used. Where the answers differ

However. what has been lacking is a practical resource

from what you might have answered, take the oppor­

for manual therapy clinicians and students who wish to

tunity to stop and reOect on the basis for your opinion.

reOect and improve on their own clinical reasoning.

Reasoning is not an exact science and the analysis of

Clinical Reasoning for ManualTherapists has been writ­

what are often complex, multifactorial patient pre­

ten specifically for that purpose. This text will also pro­

sentations cannot be reduced to simple correct versus

vide manual therapy educators \vith a valuable bank of

incorrect interpretations. For these cases to achieve

patient cases that can be utilized in learning activities

their full educational potential. readers must attempt

designed to facilitate students' clinical reasoning.

to reason through each case themselves and then openly reOect on and critique the reasoning expressed, the evidence substantiating judgments made and,

Outline of the book

importantly, your own reasoning. regardless of whether you agree or disagree with that put forward by the

The book commences "vith a theory chapter (Chapter 1)

expert clinician.

on clinical reasoning covering both basic and con­

In order to achieve our aim of providing a resource

temporary clinical reasoning theory. It is hoped that

that will assist students and clinicians to improve their

readers will read this chapter prior to progressing to

clinical reasoning, it was essential to include a chap­

the case studies. as the clinical reasoning questions

ter on educational theory and principles related to

posed to the case contributors and the clinical reason­

learning clinical reasoning. Chapter 25 by Joy Higgs

ing commentary that follows their answers draw on

provides this background. While the relevance of this

this theory. Section 2 (Chapters 2-24) is a compilation

chapter to manual therapy educators (including

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clinical supervisors) is obvious, the theory and prin­

alternative but readily accessible resources. There are

ciples discussed are equally essential to practising clin­

learning activities that can be undertaken alone by

icians. Teaching is a central component of manual

the individual clinician, activities that involve a col­

therapy practice, and patient learning (e.g. altered

league or mentor and ones that can be undertaken

patient understanding/beliefs. feelings and health

within the smaU group situation. The continual process

behaviours) is a primary outcome sought from collab­

of learning clinical reasoning in both real life and simu­

orative reasoning. As very few manual therapists

lated clinical experiences is discussed in depth and

have received any formal schooling in education or

made practical. Examples of high-technology learn­

learning theory, this chapter is vital to be able to pro­

ing activities (e.g. commercially available interactive

mote effectively change in your students. your patients

computer programmes) and low-technology learning

and yourselr.

activities (e.g. the use of a rellective diary) are given

Lastly, Chapter 2 () has been written to assist those

and their 'pros and cons' debated. Indeed. there is a

clinicians and students who wish to continue to

learning experience suitable for every therapist or stu­

improve their clinical reasoning and for educators of

dent. no matter what their stage of education. learn­

manual therapy who desire to enhance the develop­

ing style or available resources.

ment of such skills in their students. We view clinical

We expect that this book will be of benefit for stu­

reasoning as an essential competency in manual ther­

dents studying manual therapy and lor the v arious

apy and, like any competency. skill is only acquired

types of clinician working in this field and will provide

through continued practice, rellection. feedback and

a valuable resource for instructors. To make the most

then further practice. In this chapter. following a dis­

of the book. the reader should strive to keep in mind

cussion on the development of clinical expertise and

that the learning of clinical reasoning and the devel­

common clinical reasoning errors. we provide a var­

opment of related thinking skills requires the individ­

iety of suggestions for learning activities that can be

ual to participate actively in their learning and at all

used to further practice and develop your clinical

times maintain an open but sceptical mind during

reasoning skills (or that of students). Some of these

this process. Consequently. the acquisition of clinical

activities involve using the patient cases found in

reasoning skill. and hence expertise in manual ther­

Section 2. as previously discussed. while others utilize

apy. is in your hands.

• Reference Higgs. J. and Jones.

M. (eds.) (2000). Clinical Reasoning in the 2nd edn. Oxford: Butterworth-Heinemann.

Health Professions.

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Principles of clinical reasoning in manual therapy II Introduction to clinical reasoning Mark A. Jones


and Darren A. Rivell

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Introduction to clinical reasoning •

Mark A. Jones and Darren A. Rivett

Maoual therapists work with a multitude of problem presentations in a variety of clinical practice environ­ ments (e.g. outpatient clinics, private practices, hos­ pital or outpatient-based rehabilitation and pain unit teams. sports settings, home care and industrial work sites). The clinical presentations they encounter are, therefore, varied, ranging from discrete well-defined problems amenable to technical solutions to complex, multifactorial problems with uniqueness to the indi­ vidual that defy the technical rationality of simply applying a 'proven' set course of management. Schon (1987, p. 3) characterizes this continuum of profes­ sional practice as existing between the 'high, hard ground of technical rationality' and 'the swampy low­ land' where 'messy, confusing problems defy tedmical solution'. As will be evident in the case studies of this book, manual therapists must. therefore, be able to practise at both ends of the continuum. Manual ther­ apists must have a good biomedical and professional knowledge base as well as advanced technical skills to solve problems of a discrete, well-defined nature. However. to understand and manage successrully the 'swampy lowland' of complex patient problems requires a rich blend of biomedical, psychosocial, pro­ fessional craft and personal knowledge, together with diagnostic, teaching, negotiating, listening and coun­ seJJing skills. Contemporary manual therapists must have a high level of knowledge and skills across a comprehensive range of competencies, including assess­ ment, management, communication, documentation, and professional. legal and ethical comportment. Effective performance within and across these competencies requires a broad perspective of what

constitutes health and disability and equally broad skills in both diagnostic and non-diagnostic clinical reasoning. In this chapter we present a contemporary per­ spective on clinical reasoning in manual therapy. Clinical reasoning is portrayed as being multidimen­ sional. It is hypothesis oriented. collaborative and rel1ec­ tive. Skilled clinical reasoning contributes to therapiSts' learning and to the transformation of existing perspec­ tives. A framework that describes the organization of knowledge by manual therapists is proposed together with a model of health and rusabiUty/recovery. We consider these will be helpful in promoting a broader perspective on patients' problems and will serve as a reference for exploring the reasoning of individual therapists.

What is clinical reasoning? Clinical reasoning has been defined as a process in which the therapist, interacting with the patient and significant others (e.g. family and other health-care team members), structures meaning, goals and health management strategies based on clinical data, client choices and professional judgment and knowledge (Higgs and Jones, 2000). It is this thinking and decision malcing associated with clinical practice that enables therapists to take the best-judged action for individual patients. In this sense, clinical reasoning is the means to 'wise' action (Cervero, 1988; Harris, 1993). Figure 1.1 depicts the integrated, patient-centred model of collaborative reasoning we hope to promote.

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more informalion needed


Subjective interview

Physical examination explanation more information volunteered




I+------+---.J . home exercises

Fig. 1.1


-learns •


Patient-centred model of clinical reasoning (Edwards and Jones. unpublished assignment).

In this model. clinical reasoning is seen as a process of renective enquiry comprising three core elements­ cognition. metacognition and knowledge--carried out in a collaborative framework with the relevant parties (e.g. the patient. carers, other health-care providers, the workplace and funding bodies) (Edwards and Jones,

1996: Jones et al.. 2000). Numerous variables innuence the success of this collaborative

therapist-patient reasoning process.


Understanding both the 'problem' and the 'person' determine management To understand and manage patients and their prob­ lems successfully, manual therapists must consider not only the physical diagnostic possibilities (including the structures involved and the associated pathobiology) but also the full range of factors that can contribute to a person's health. particularly the effects these

• attributes of the therapist (e.g. breadth, depth and

problems may have on patients' lives. and the under­

organization of knowledge , familiarity and experi­

standing patients (and significant others) have of

ence with the type of case being managed. reason­

these problems and their management. Skilled thera­

ing proficiency, communication and teachn i g

pists do this through a process of enquiry/interview, physical and environmental examination and ongoing

and professional craft skills) • attributes of the patient (e.g. needs, beliefs/attitudes

management, where clues gleaned from the patient's

and individual physical and psychosocial circum­

presentation elicit hypotheses regarding the person

stances, including their capacity and willingness

and their presenting problems (Jones, 1992: Jones

to participate in shared decision making and man­

et al.. 2000; Rivett and Higgs. 1997). Except in very straightforward presentations, when expert clinicians

agement) • attributes of the environment (e.g. resources. time.

are quickly able to recognize the problem and the solu­

funding, and any externally imposed professional

tion. these hypotheses then serve to guide further

or regulatory requirements).

enquiries, assessment and eventually management.

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In attempting to understand patients and their prob­ lems, manual therapists must be able to think along multiple lines and often think on different levels at the same time.

The clinical reasoning process is hypothesis oriented in that patient data prompt the therapist's consider­ ation of compeling interpretations. which are, in turn. claril'icd and lesled lhrough further data collec­ tion and reassessmenl of management interventions (Fig. 1.1). Although many therapists do not realise it, they are generating hypotheses from the opening moments of a patient encounter (Doody and McAteer, 2002; Rivett and Higgs, 1997). That is, initial cues, such as a referral, case notes, observations of the patient in the waiting room, and opening introductions and enquiries with the patient. will evoke a range of initial impressions. While typically not thought of as such, they can be considered hypotheses. These initial hypotheses may be physical. psychological or socially related, with or without a diagnostic implication. They are usually somewhat broad and serve to delin­ eate the boundaries in which the assessment will proceed . All therapists have an element of routine to their examination. Individual therapists will have identi­ fied, through experience, the categories of informa­ tion which they have found to be particularly useful for understanding and managing patients' problems. For example: •

• •

• • • •

personal profile including work, family and social circumstances site, behaviour and history of symptoms psychological/cognitive/affective status, expect­ ations and goals general medical status: clinical yellow and red flag screening occupational blue flag screening socio-occupational black flag screening functional and structure-specific tests of the cardio­ vascular. respiratory and neuromusculoskeletal systems ergonomic and environmental analysis, etc.

While a degree of routine commonly exists. the spe­ cific enquiries and tests should be tailored to each patient's unique presentation.

Narrative reasoning

Through a process of enquiry. examination and rel1ect­ ive management. the therapist attempts to understand the patient's problem, while at the same time trying to understand the patient's personal story/narrative or the context of the problem beyond the mere chronological sequence of events. Understanding the context. also called 'narrative reasoning' (Christensen et aI., 2002; Edwards, 2001; Fleming and Mattingly. 2000; Jones et al., 2000, 2002). requires attempting to understand the patient as a person. including their perspective of the problem. their experiences (e.g. understanding, beliefs, desires. motivations, emotions), the basis of their perspectives and how the problem is affecting their life (i.e. their pain or illness experience). This dimension of reasoning and understanding requires more than a good biomedical knowledge base and technical skills. Successful narrative reasoning, aimed at understand­ ing the person. requires a good organization of bio­ psychosocial Imowledge and the communication skills in order to apply that knowledge successfully. Narrative reasoning also necessitates a level of openness on the part of the therapist. both v\lith respect to accepting the patient's story and with awareness of their own per­ sonal perspectives, and even biases. on matters such as chronic disability and pain. compensation cases and cultural issues. Therapists' personal perspectives on such issues will influence their approach (e.g. attitudes. expectations, communication/relationship) to their patients and their problems, with rel1ection required to recognize, and where necessary alter. inaccurate or unhelpful perspectives. Patients' understanding/beliefs, attitudes. emotions and expectations represent what Mezirow (1990, 1991) has called their 'meaning perspective' (syn­ onymous with 'frame of reference'). Understanding a patient's meaning perspective is the basis of narrative reasoning. An individual's meaning perspective is acquired and evolves from a combination of personal, societal and cultural experiences. where conscious and unconscious interpretations. attributions and emotions coalesce to make up their views and feel­ ings. Mezirow (1991. p. xiii) states, ' ... that it is not sO much what happens to people but how they interpret and explain what happens to them that determines their actions. their hopes. their contentment and emotional well-being, and their performance'. In this sense. patients' meaning perspectives create sets of habitual expectations that serve as a (usually

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tacit) belief system for interpreting and evaluating experiences. In the context of manual therapy, patients' meaning perspectives become f1lters through which their perceptions and comprehension of any new experience must pass. Therefore, if a patient's mean­ ing perspective is distorted-judged by the therapist to be counterproductive to recovery-such as 'pain equals further damage' or 'the damage I have is per­ manent and I will not improve further', then their perception (or lack of ) and interpretation of new experiences (including the therapist's assessment and management) will also be distorted. In fact , distorted meaning perspectives or beliefs are typically more rigid and less amenable to change (Mezirow, 1991). Analogous to attempting to identify underlying physical contributing factors to patients' symptomatic structures, it is necessary for manual therapists to delve into the basis of patients' meaning perspectives (i.e. their understanding. emotions. beliefs and attri­ bu tions) in order to understand these perspectives. Patients' meaning perspectives are re!1ected in their 'story' or the context in which those views were shaped. While sometimes the information comes forward spon­ taneously. therapists must be able to listen for and enquire about (i.e. screen) patients' meaning perspec­ tives and their basis, so as to identify patterns of dis­ tortion that require attention. While some patients' perspectives will fit recognizable patterns, others will be unique and defy some universal truth of 'normal' or 'unhelpful'. In other words. narrative reasoning decisions cannot be reduced to a correct or incorrect empirical judgment. Rather. therapists' hypotheses regarding patients' meaning perspectives can only be validated through therapist-patient consensus, or what has been labelled communicative (as opposed to pro­ cedural) management. As it is beyond the scope of this chapter to cover the full range of psychosocial issues for which therapists should screen, readers are referred to the texts by Butler (2000), Main and Spanswick (2000a), Strong et al. (2002) and Gifford (2000) for more thorough discussions of psychosocial screening.

Diagnostic versus narrative reasoning A distinction can then be made between understanding and managing the problem to effect change (requiring biomedically driven cause and effect thinking and action: diagnostic reasoning and procedural management) versus understanding and interacting with the person to effect change (requiring biopsychosocially driven

narrative reasoning and communicative management). In reality, a comprehensive diagnosis should encompass what is learned from both the diagnostic reasoning regarding the physical problem and the narrative rea­ soning regarding the person. All forms of reasoning and management should be carried out collaboratively. These seemingly different foci of thinking and management (directed to the problem and directed to the person) are not mutually exclusive. as the under­ standing of one enhances the therapist's understanding of the other. For example, attempting to understand and then attempting to facilitate change in the person (e.g. beliefs. emotions and health behaviours) is aided through a greater insight into the problem. The extent and nature of patients' activity and participa­ tion restrictions (World Health Organization. 2001; i.e. physical disabilities and associated handicaps) and impairments forms part of the context in which their psychosocial status must be viewed. A degree of stress and feelings of frustration, anger and even depression may be quite 'normal' in the presence of marked restrictions in activity and participation. Maladaptive thoughts and feelings can also coexist with physical impairment without necessarily driving or being the underlying source of those restrictions. Similarly, however. understanding a problem and then attempting to facilitate change (e.g. activity restrictions and physical impairments) is aided through greater insight about the person. Patients' feelings. beliefs and health behaviours may be contributory to the recovery or detrimental (i.e. counterproductive to their recovery), and judgments regarding these aspects of the patient require effective interpersonal and enquiry skills. including biopsychosociaJ knowledge of what to look for, management strategies and referral pathways. Just as activity restrictions (e.g. dHficulty climbing stairs) must be considered with respect to any physical impairments that may be present (e.g. mobility and motor control), the patient's feelings. beliefs and health behaviours must also be considered \\Tith respect to their experiences and related consequences, which may have contributed to shaping their views and behaviours (Butier. 2000; Gifford, 1998a. 2001. 2002; Main and Booker, 2000; Main and Parker, 2000; Watson, 2000; Watson and Kendall. 2000). Success in promoting change in both the problem and the person necessitates fostering the patient's insight into their own feelings. beliefs and behaviours, including their basis and where change would be beneficial. Reaching this level of mutual understanding requires collaborative

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reasoning or shared decision making between patient

par ticular, manual therapy intervention (procedural

and therapist. as well as therapist skills in communi­

and communicative) serves as another test of the

cating and teaching. Similarly. as the physical and the

hypotheses formed, consensus made and subsequent

psychological are closely linked. both procedural man­

chosen course of action. Re-assessment either provides

agement, consisting of physically oriented active and

support for these decisions or signals the need for modi­

passive interventions. and communicative manage­

fication (of hypotheses). further perspective discus­

ment. consisting of education, advice and consensual

sion (Le. revisit the previous consensus reached) or

perspective re-evaluation,

further data collection (e.g. additional clinical exam­

will affect the other.

For the purposes of this book, hypothesis-oriented

ination or referral for other health professional consult­

reasoning is defmed very broadly as the reflective

ation). At the micro level. therapists are constantly

process of attending to patient information by con­

attending to patient responses (e.g. listening. clarify­

sciously attempting to relate different features either to

ing, obserVing, feeling) and using these to build their

recognizable clinical patterns or to new, previously

understanding and guide clinical decisions to modify

unrecognized patterns unique to the individual. Reflect­

and improve their interventions. At the macro level,

ive attention to different patient cues and the subse­

whole treatment sessions or even multiple treatments

quent critical search for supporting/conflrming cues is

will be used to test the therapist's and patient's under­

put fonvard as essential to

standing and shared management decisions.

aU reasoning processes,

including attempting to understand the person and

Although this account of management/re-assess­

attempting to understand the problem. This cognitive

ment is described within the hypothesis-oriented

activity of interpreting patient cues with respect to


information already obtained represents a form of

throughout management cannot be simply reduced






hypothesis testing and includes attending to and

to an empirical-analytical approach. The various forms

searching for both supporting and negating evidence.

of management (e.g. specific procedures, therapist­

As referred to above. while some interpretations can be

patient communication during management and

empirica.lly validated. others will only be validated

teaching) can be carried out both in an instrumental

through therapist-patient consensus of the situation

cause and effect approach. where specified. measur­

(e.g. patients' beliefs/perspectives and the basis on

able outcomes are sought. and in a communicative

which they were formed). As the patient's story unfolds,

approach, where absolute truths are not available

the cumulative information obtained is interpreted ['or

and validation is achieved through therapist-patient

its lit with the broader evidence from available research

common understanding and consensus.

and the particular patient's presentation. including pre­

Cognition, featured in the left-hand box in Figure

viously obtained data, hypotheses considered and con­

1.1, is purposeful thought. The cognition underlying

sensus reached. Even routine enquiries. tests and

clinical reasoning includes the perception of relevant

spontaneous information offered by the patient will be

information, specific data interpretations or induc­

interpreted in the context of initial impressions or

tions; drawing inferences and generating hypotheses

hypotheses. In this way. the manual therapist acquires

(deductions) from the synthesis of multiple cues; and

an evolving understanding of the patient and the

testing for competing hypotheses. Higher-order cogni­

patient's problem(s). Initial impressions ,.viII be modified


and new ones considered. The therapist's hypothesis­

of one's own thinking and understanding is discussed

(metacognition) in the ['orm of reflective appraisal

oriented diagnostic and narrative reasoning continues

below under Reasoning as a reflective process.

until sufficient understanding (of the person and the problem) is reached by both therapist and patient to enable joint determination of a plan of management.

Pattern recognition Pattern recognition is a characteristic of all mature thought. In .both everyday life and in the realm of

The role of re-assessment in reasoning

manual therapy, knowledge is stored in our memory in chunks or patterns that facilitate more efficient

The clinical reasoning of the therapist and patient

communication and thinking

continues throughout the ongoing management. In

Ericsson and Smith, 1991: Hayes and Adams. 2000;

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(Anderson, 1990;


Newell and Simon. 1972: Rumelhart and Ortony. 1977; Shon. 1983). These patterns form prototypes of frequently experienced situations that individuals use to recognize and interpret other situations. In manual therapy. patterns exist not only in classic diagnostic syndromes and associated management strategies but also in the pathobiological mechanisms associated with those syndromes and the multitude of environmental. physical. psychological (cognitive and affective). social. behavioural and cultural factors that contribute to the development and maintenance of patients' problems. For example. it is possible to recognize the typical clinical features of a shoulder subacromial impingement problem. as well as differ­ ent patterns of common anatomical. biomechanical. motor and technique/equipment factors that can contribute to this disorder. Importantly. patients can have the same pathology but quite differ­ ent contributing factors. necessitating different and very individualized management if success is to be realised and maintained. Manual therapists also must be able to recognize patterns of biomedical factors that contraindicate manual therapy. such as clinical red jlags (i.e. serious organic pathology) (Roberts. 2000) and biopsychosocial personal. family and work-related factors (yellow. blue and black nags. respectively) that may predispose to chronic pain. prolonged loss of work and serve as potential obstacles to recovery (Kendall et a1.. 1997: Main and Burton. 2000; Main et a1.. 2000). These are further discussed below under Prognosis. Pattern recognition is required to generate hypoth­ eses and hypothesis testing provides the means by which those patterns are reflOed. proved reliable and new patterns are learned (Barrows and Feltovich. 1987). While expert therapists are able to function largely on pattern recognition. novices who lack suffi­ cient knowledge and experience to recognize clinical patterns will rely on the slower hypothesis testing approach to work through a problem. However. when confronted with a complex. unfamiliar problem. the expert. like the novice. will rely more on the hypothesis­ oriented method of clinical reasoning (Barrows and Feltovich. 1987: Patel and Groen. 1991). Narrative reasoning and communicative management are still required to reveal and act on patients' meaning per­ spectives. regardless of whether pattern recognition or hypothesis testing dominates. Despite pattern recognition being a mode of thinking used by experts in all professions (Schon. 1983). it also represents perhaps the greatest source of errors in our thinking.

Related and other common errors of clinical reason­ ing are discussed in Chapter 26.

Reasoning as a collaborative process Successful management of patients' problems requires more than just good diagnostic and manual skills: manual therapists must also be good teachers. In fact. while a certain percentage of patients' problems can be forever resolved through the sole intervention of the therapist's manual techniques. often lasting changes are only effected by understanding the par­ ticular determinants of health and behaviour operat­ ing and by negotiating changes in the patients' understanding. beliefs/attitudes and behaviours. For example. patients' understanding of their problems has been shown to impact on their self-efficacy. levels of pain tolerance. disability. time off work and even­ tual outcome (Borkan et al.. 1991: Feuerstein and Beattie. 1995; Lackner et aI.. 1996: Main and Booker. 2000; Main et al. . 2000; Malt and Olafson. 1995: Strong. 1995: Watson. 20(0). Manual therapists have generally only learned through personal experience the ski Us of psychosocial assessment and management (e.g. listening. commu­ nicating. negotiating. counselling and motivating) needed to effect positive changes in their patients' health understandings. beliefs and behaviours. While such skills are increasingly being made more explicit in manual therapy curricula. in general these aspects have not historically been given the same attention in terms of theory and application as has clinical reasoning in physical diagnosis and management. Consequently. biopsychosocial knowledge and inter­ personal skills are often tacit and underdeveloped in some therapists. The collaborative nature of the reasoning process is highlighted by the arrows interconnecting the centre and the boxes on the right in Figure 1.1. Whereas the centre boxes feature the therapist's reasoning. the boxes on the right depict the patient's thoughts and understanding. Thus. patients begin their encounter with a manual therapist with their own ideas of and feelings about the nature of their problem(s) and the management they need. as shaped by personal experience and advice from medical practitioners. family and friends. Through a process of evaluating patients' understandings. beliefs and feelings (meaning perspectives). and through the use of explanation.

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reassurance and shared decision making. the therap­ ist can involve the patient in developing an evolving understanding of the problem and its management. Beliefs and feelings that are counterproductive to a patient's management and recovery. such as exces­ sive fear of movement or pain. can contribute to phys­ ical deconditioning. poor compliance vvith self­ management. poor self-efficacy and ultimately a poor outcome (Hill. 1998: Main and Booker. 2000). Patients who have been given an opportunity to share in the decision making have been shown to take greater responsibility for their own management and have a greater likelihood of achieving better outcomes (Bucklew et aI., 1994: Burkhardt et al.. 1994; Lorig et al .. 1999: Niestadt, 1995: Shendell-Falil<. 1990), Patient learning is a primary outcome sought from collaborative reasoning (Jones et at.. 2000). Rather than being passive recipients of health care, patients construct a new understanding or meaning perspec­ tive. one in which they are actively involved in man­ agement decisions and share in the responsibility for their health care. While tbis discussion has focussed on the collabora­ tive reasoning between therapist and patient. a Similar collaborative process should exist between the therapist and carers. as well as with other members of the health-care team and funding bodies. This broader role of the manual therapist in the local and global health­ care community as an interactional professional is dis­ cussed more extensively in Higgs and Hunt (1999a.b).

manual therapists. neurological physiotherapists and domiciliary care physiotherapists skilfully employed such reasoning. It occurs on different levels from the provision of simple advice to motor retraining and explanation directed to changing patients' meaning perspectives. In all situations. the therapist must make judgments concerning the level and amount of teach­ ing that is appropriate for an individual patient and the mode of delivery that is most suitable and likely to be accepted by the patient. For example. expert therap­ ists will often strategically use 'stories' regarding other patients as a means of building rapport. educating and communicating prognostic outcomes (Edwards. 2001). Such real-life scenarios bring credibility to the advice or explanation that they are used to support and can be strategically employed by therapists to strengthen their message. Learning theory is discussed in Chapter 25. where transformative learning (described by Mezirow (1990) as perspective transformation) is defined as the con­ struction of meaning (Le. knowledge) from experi­ ence. The individual's revised understanding will then guide their future perspectives (understanding. appreciation and behaviour). Facilitating this level of learning necessitates the learner (patient or therapist) engaging in critical rel1ection. Presuppositions of current beliefs are re-examined. opening the way for new. revised perspectives. Both therapists and patients at times need to renect critically on the basis of their beliefs. so that distortions in meaning per­ spectives (beliefs) may be identified and corrected.

Reasoning as a reflective process

Learning from reflection

Learning should be seen as a central outcome of clin­ ical reasoning for both therapist and patient. While all therapists would hopefully see themselves as both teachers and learners. learning theory has traditionally not been a core area of study for manual therapists. apart perhaps from the formal attention to learning theory that accompanies concepts of motor learning. However. given the importance most therapists would acknowledge teaching has in their patient manage­ ment (Jensen et al.. 1999. 2000: Sluijs, 1991). this is an obvioLls deficiency.

Teaching Teaching is a ubiqUitous activity requiring its own focus of reasoning. Edwards (20CH) found that expert

To learn from your own cUnical experiences and grow as a therapist requires reasoning that is open minded and rel1ective, Reflection is an act of cognition that can be used in different ways, In a simplest form. these thoughtful activities represent reflective thought. for example. when the significance of a piece of informa­ tion is actively considered or when different and sometimes connicting findings are assessed. However. rel1ective thinking at a higher level. metacognition. involves thinking about your thinking and the factors that limit it. Metacognition is a well-recognized char­ acteristic of expertise (Alexander and Judy, 1988: Biggs. 1986). Metacognitive reflections may be directed at any of the following: •

the information available (e.g. awareness of the quality and relevance of information obtained)

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the reasoning process (e.g. awareness of specific strategies required to understand the person and the problem and achieve the desired goals) • the hypotheses rormed and decisions reached (e.g. research and experience-based evidence for assess­ ment and management decisions) • the organization of knowledge (e.g. awareness of one's own knowledge base, personal perspectives. biases and any limitations).

Reflection can occur in what Schon (1983. 1987) has called rej1ection-in-action, where you literally pause during a patient encounter and consider any of these issues , or in hindsight as a rej1ection-about­ action. Too often a patient's status changes. for the better or the worse. without the therapist having or taking the time to reflect on the change. In a busy practice. improvement is a godsend as it means the treatment can be repeated with little deliberation. A lack of improvement typically leads to a change in treatment with some consideration of the options available. but often without any serious reflection on prior judgments made and the underlying reasoning that led to the current lack of improvement. The reflective thinker is sceptical. always question­ ing the reliability. validity and overall relevance of findings and interpretations. and ever prepared to accept that their own knowledge base may be inad­ equate. Brookfield (1987.2000) cites this trait as a key component of all critical thinking. not just clinical reasoning. He stresses the importance of being will­ ing and able to identiry and challenge the assump­ tions that underlie beliefs and actions. Reflecting on the basis of one's preconceptions may include con­ Sidering such things as what information is relevant: what constitutes a particular diagnostic, psychosocial or behavioural pattern: what evidence (research valid­ ated or experience based) exists to support judgments and inter ventions: and the appropriateness or the model or health and recovery followed.

Awareness of new perspectives Associated with becoming aware of the assumptions that underlie a belier is the recognition of the context from which those assumptions arose. That is. many of our beliefs are formed from cultural. historical or specific philosophical frames or reference: when these rrames of reference are appreciated. a deeper

understanding of the belier itself and a more informed position from which to evaluate the belief can be achieved. A healthy reflective scepticism, where a par­ ticular philosophy, position or justification is not taken for granted simply because it has been presented by a source or authority or been unchanged for a long time. is important for skilled clinical reasoning and continued profeSSional growth. This is not to suggest that the only legitimate decisions and actions are those that can be conclUSively substantiated by cur­ rent research. as we hold the view that experience­ based non-propositional and personal knowledge. as discussed below. are equally important (Higgs et al.. 200la: Jones and Higgs. 2000). is import­ ant to recognize the basis and biases of one's own views and that alternatives exist. This requires look­ ing beyond your own perspectives and contemplating other possibilities.some or which may even be beyond what is empirically known at the present time. Such open reflection about oneself (by therapists and patients) is no easy task. as Brookfield ( 2000. p. 63) points out: No matter how much we may think we have an accurate sense of our practice. we are stymied by the fact that we are using our own interpret­ ive filters to become aware of our own interpret­ ive filters! ... To some extent we are all prisoners trapped within the perceptual rrameworks that determine how we view our experiences. A selt� confirming cycle often develops whereby our uncritically accepted assumptions shape clin­ ical actions which then serve only to conl1rm the truth of those assumptions. Because of this. it is usually difllcult to explore your own assumptions effectively. Clinical reasoning in gen­ eral. and self-reflection in particular, is enhanced when we enlist the help of others. On this basis, Brookfield (2000) describes clinical reasoning as an inherently social process. Peers. teachers and also our patients can be erfective critical mirrors. as we can be to our patients, to foster the critical self-reflection necessary to promote change. Brookfield labels the reluctance most of us have for this (i.e. to exposing our reasoning to the critique of others) as 'impostorship': the deep feeling many clinicians have that they do not really under­ stand a problem or how best to manage it and their rear of being 'found out' by the patient and their col­ leagues. Acknowledging this realil)' is critical ir thera­ pists are seriously trying to improve their own clinical

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reasoning. Section 3 discusses ways in which this bar­ rier can be broken down and in which critical reflection, and hence transformalive learning, can be facilitated. A key attribute of experts, and a necessary pre­ requisite to skilled clinical reasoning, is the affective disposition to think in this reflective manner. Such an affective disposition includes inquisitiveness, self­ confidence, open mindedness, flexibility, honesty, diligence, reasonableness, empathy and humility (Brookfield, 1987; Ennis, 1987; Fonteyn and Ritter. 2000; Jensen et al.. 1999). Clearly critical thinking. as well as being rational. is emotive.

Reasoning requires well-organized knowledge Research investigating the nature and development of expertise across a range of activities (chess, engineer­ ing, mathematics, medicine, physics, statistics) has consistently shown that it is not the command of any generic problem-solving strategies or how much knowledge is possessed that is critical; rather. it is how that knowledge is organized (Allwood and Montgomery. 1982; Arocha et aI., 1993; Bloom and Broder. 1950; Bordage and Lemieux, 1991: Boshuizen and Schmidt, 2000: Chi et al.. 1981: De Groot. 1965; Patel and Groen. 1986; Patel and Kaufman. 2000; Schmidt and Boshuizen. 1993). As previously discussed, humans store knowledge in chunks or patterns. Therefore, one can think of therapists' organization of lmowledge as the breadth and depth of their understandings and beliefs, held together in patterns acquired through both formal academia and personal experience. remembering that diagnostic patterns represent only a fraction of one's knowledge base. In fact. knowledge focussing purely on biomedical. diagnostic pathology is insufficient for full understanding and manage­ ment of patients' problems. Rather this propositional textbook knowledge must be integrated into a broader organization of non-propositional craft and personal knowledge. Understanding of patients' personal con­ texts, strategies of reasoning and intervention. and awareness of your own perspective. are important aspects of professional craft and personal lmowledge. It is beyond the scope of this chapter to explore this importanl topic of knowledge types and knowledge acquisition fully, and readers are referred to the work of Boshuizen and Schmidt (2000). Higgs and Titchen (2000). Higgs et al. (2001b) and Patel and Kaufman

(2000) for further discussion of these issues. For the purposes of this book, we will use the broad distinction (proposed by Higgs and Titchen (1995)) of propos­ i tional knowledge (or 'knowing that'-biomedical and biopsychosocial knowledge ratified by clinical trials and well-founded theories of professional practice) and non-propositional knowledge, including professional craft knowledge (procedural knowledge or 'knowing how', such as practical skills and strategies of enquiry, reasoning and intervention) and personal knowledge (knowledge derived from personal experiences, which shapes your own unique meaning perspectives and influences your interpersonal interactions, personal values and beliefs). Understanding and successfully managing patients' problems requires a rich organization of all three types of knowledge. Propositional LmowJedge provides us with theory and levels of substantiation by which the patient's clinical presentation can be considered against research-validated theory and practice. Non­ propositional professional craft knowledge allows us the means to use that theory in the clinic while providing additional, often cutting-edge (albeit with unproven generality) clinically derived evidence. Per­ sonal knowledge allows a deeper understanding of the clinical problem to be gained within the context of the patient's particular situation and enabling us to practise in a holistic and caring way. As important as knowledge obviously is to success­ ful clinical reasoning, improving one's organization of knowledge requires a clear understanding of how knowledge is acquired. Glaser (1984, p. 99) states that 'effective thinking is the result of conditionalized knowledge-the knowledge that becomes associated with the conditions and constraints of its use'. That is. knowledge is made particularly meaningful and accessible when it is created or acquired in the context for which it must be used (Cervero, 1988: Rumelhart and Ortony. 1977; Schon, 1983, 1987; Shepard and Jensen. 1990; Tulving and Thomson, 1973). In manual therapy. this means acquiring and constructing Jinks between propositional, professional craft and personal lmowledge in the context of real-life patient problems. This view is consistent with the stage theory of knowledge acquisition and development (Boshuizen and Schmidt, 2000). This proposes that medical students initially function predominantly on biomed­ ically dominated propositional knowledge structures. which gradually become encapsulated into clusters of higher-order concepts (e.g. clinical syndromes). In other

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words, with clinical experience, textbook knowledge is eventually transposed into clinical patterns anchored within memory through real clinical experiences (Bosh uizen and Schmidt. 1 992, 2000: Schmidt et al.. 1 990, 1 992), The notion of an 'illness scri pt' is used to depict this higher-order knowledge structure (Feltovich and Barrows, 1 984). Illness scripts have three components: enabling conctitions: conditions or constraints under which a disease or problem occurs, such as personal, sociaL mectical, hereditary and environmental factors • fault: the pathobiological and psychosocial processes associated with any given disease or disability • consequences of the fault: signs and symptoms of the particular problem as well as its f unctional impact on the patient's life.

Even this probably oversimplifies the complexity of a clinician's knowledge organization. Virtually every characteristic of a patient ' s presentation (enabling conditions, rault and consequences) can be said to exist along a continu um. and judging the relevance of a particular feature often relates to its qualitative characteristics and perceived dominance within the presentation (Bordage and Lemieux , 1 986: Bordage and Zacks, 1984). Therefore. in addition to recogniz­ ing clinical presentations, therapists must also pos­ sess a broader understanding of the determinants of health and recovery. Patel and Kaufman ( 2000) challenge the model or knowledge encapsulation put forward by Boshuizen and Schmidt (2000), suggesting it represents an ideal­ ized perspective on the integration of basic science in clinical knowledge and argue that biomedical know­ ledge and clinical knowledge are two separate worlds. They suggest basic science has different Significance in different domains, and cite research which has demonstrated that even 'expert' medical clinicians have poorly developed biomedical knowledge. They propose that the key role played by basic science may not be in facilitating clinical reasoning per se but in facilitating explanation and coherent communica­ tion. The debate regarding the role of biomedical knowledge is equally important to manual therapy curricula, where some are grounded in promoting clinical decisions on the basis of the patient's presenling signs and symptoms (i.e. impairment based with con­ sideration of but not driven by biomedical factors) while others have pathology and biomedical con­ structs as the focus of assessment and management.

model ' We support a model of knowledge organization (and hence curriculum development) that draws on both traditions but is arguably broader in scope. An excit­ ing new model proposed by Gifford ( l 998b), the mature organism model (Fig. 1 . 2), provides a concep­ tual framework that we consider will assist therapists to take up this broader perspective. It depicts the interactions of the fundamental pathways (input. processing and output) into and out of the central nervous system (eNS) that are necessary lor survival and for the maintenance of health , as well as for the development and continuation of poor health (e.g. pain and disability). Input mechanisms (i.e. all sensory pathways) sam­ ple tissue health and conununicate this together with contexlual information about the environment. includ­ ing the immediate environment surrounding an injury and the ongoing environment that makes up a per­ son's pain or illness experience. The brain can then be said to scrutinize (both consciously and unconsciously) incoming information , along with existing engrams of past experiences, for processing to the output m(,c/I­ arzisms (i.e. somatic motor, autonomic, neuroendocrine, neuroimmune and descending feedback/conlrol sys­ tems). Importantly, how the person's health is then manifest via these output mechanisms (behaviourly, cognitively. emotionally and phYSiologically) depends, in part, on the contextual factors within the person's immediate circumstances, as well as past experiences that have contributed to the person's beliers , attitudes,




on plus altered thoughts

Pain perception plus altered '"lings

cognitive dimension affective dimension

\ 1 /.

Gives Va.hM

10 expenence

t Further





, Output = Altered behavio ... Altered physiology


Fig. 1 .2

The mature organism model. (With permission

from G iffo rd, L.S. (1 998b). Pain, the tissues and the nervous system: a conceptual model. Phys iotherapy, 84, 27-36.)

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emotions and behaviours. In other words. even given the same extent of tissue injury or illness. no tvvo people will have exactly the same presentation because how they manifest their pain or illness is shaped in part by who they are. Hence. it is inadequate to focus simply on physical diagnosis. Managing patients' problems also requires understanding their unique pain or ill­ ness experiences (thcir understanding. beliefs. feelings. and coping strategies). While all input. processing and output mechanisms will be in operation in any state of ill-health. they will not all necessarily be impaired (i.e. contributing to the problem and/or counterproductive to recovery). Hence. manual ther­ apists must have the necessary knowledge organization and reasoning skills to distinguish between adaptive/ helpful and maladaptive/unhelpful mechanisms and responses. Even those problems that are seen as primarily nociceptive or residing in the tissues can be occurring alongside maladaptive psychological or behavioural 'responses '. which provide powerful barriers to active rehabilitation and the restoration of physical confidence. For example. a patient may have a lack of insight into the factors inOuencing their problem. which can create obstacles to their improve­ ment until addressed through narrative reasoning and communicative management. At a more physical levcl. prolonged stress not only can lead to increased levels of tissue sensitivity (i.e. secondary hyperalgcsia) but can also predispose to diminished tissue health via associated impairment within the neuroendocrine system (Butler. 2000: Gifford. 1 998c: Main et al.. 2000: Martin. 1997; Sapolsky. 1998). Here assessment of stress as a con­ tributing factor (along with the associated cognitive. behavioural and emotional effects) is clearly essential to understanding and managing the problem. Based upon this knowledge and reasoning. the clinician is then able to make sound decisions (for and with the client) that relate to assessment of the complete problem. including aSSOCiated cognitive. behavioural and emotional effects. and appropriate management strategies. Understanding and managing patients' problems requires a broad perspective of the multiple determinants of health and recovery. together with effective reasoning skills to apply that knowled ge. The mature organism model was developed to encourage and allow therapists (and patients) to be able to con­ sider openly and without prejudice the multiple factors and multiple levels involved in all pain presentations. it provides a broad conceptual framework from which

any of its elements (e.g. tissue mechanisms. pain mech­ anisms. effector mechanisms and psychosocial factors) and their respective clinical features or inter-relation­ ships can be explored fur ther (Jones et al.. 20(2).

• Hypothesis categories From the mature organism model. clinical patterns can be idcnlilled within the three categories of pain mechanisms (input. proceSSing and output). Under­ standing patients' problems requires understanding their unique presentations. including any activity/ participation restrictions. their individual perspectives on their experiences and the physical impairments they may have. This information can then be interpreted with respect to which pain mechanisms are dominant. what structures or tissues sources may be associated with specific physical impairments found. possible contributing factors. precautions. management and prognosis. This can be considered as representing 'categories of hypotheses' (see Table 1 .1) that musl be appreciated to understcUld fully patients and I'heir problems and to identify Clppropriate management strategies. The concept of hypothesis calegories was first introduced by Jones ( 1 9 8 7). but since then the specific categories considered important to manual therapy practice and the terminology used to des­ cribe them has continued to evolve (Butler. 2000: Christensen et al.. 2002: Gifford. 19 9 7; Gif ford and Butler. 19 9 7 : Jones. 19 9 2. 1995: Jones et al .. 2000. 2002; World Health Organization. 2001). These hypotheses should be formulated within broader conceptual models of health and disability, such as the mature organism model (Gifford. 1 9 9 8a) discussed here. Hypothesis categories can assist ther­ apists to relate the various elements of G ifford's model to the particular types of clinical decision required in contemporary manual therapy.

Activity and participation capability/restriction Activity restriction refers to difnculties an individual may have in executing activities. where participation restriction refers to problems an individual may have with involvement in life situations. These terms replace the previous terms disability and handicap. respectively. and are also synonymous with the 'dysfunction' hypothesis category. which has been previously used

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Table 1 . 1

Hypothesis catego ries: categories of judgments

the patient can succeed with. Similarly, general phys­

that assist in understanding the patient as a person and

ical and social reactivation commences from what the

thei r problem(s)

patient can do and from there aims to increase their

• Activity capability/restriction (abil ities and difficulties an

activity and participation levels progressively.

individual may have in executing activities) and Participation capability/restriction (abilities and

problems a n individual may have i n i nvolvement i n life situations)

Psychosocial factors: patients' perspectives on the i r experience

• Patients' perspectives on their experience

Patients' perspectives on their experience are synonym­

• Pathobio/ogical mechanisms (tissue healing mechanisms and pain mechanisms)

ous with other terms used in the l i terature including

• Physical impairments and associated structure/tissue sources

their psychosocial status, their cogni tive and affective status. their psychological or mental status and. as discussed earlier in this c hapter, their pain or illness

• Contributing factors to the development and

experience. In reality. when a patient's activity and

maintenance of the problem

participation restrictions are identified. consideration

• Precautions and contraindications to physical

should be given to any physical , psychosocial or envir­

examination and treatment

• Management and treatment

onmental factors that may be causing or contributing

• Prognosis

to those restrictions. Hence patients' perspectives is actu a l ly a su bcategory of 'contributing factors' dis­ cussed below. However, patients' perspectives on their

1997). The case contributors

experience has been listed as a separate hypothesis

in Section 2 use all of these terms somewhat inter­

category simply to signpost the importance of this

changeably. Examples of activity restrictions include

area of understanding. which historically was not

functional d irficulties. such as ascending/descending

formally considered by manual therapists.

(e.g. Gi fford and Bu tler.

stair s . walking. lifting. prolonged sitting. etc. Partici­

It is now well recognized that patients' perspectives

pation restrictions relate to the life involvement con­

can be obstacles to their recovery. either as antecedents

sequences o f activity restrictions such as restrictions

to their pain states and activity/participation restric­

i n participation in work or family d u ties or limitations

tions or as consequences (e.g. Butler, 2 0 0 0 ; Gifford.

in sport or leisure participation.

2 0 0 0 ; Main and Booker, 2 0 00; Main and Burton.

However, the patient's presentation cannot fully

2000; Main and Parker. 2000; Main et a l . . 2000;

be understood by only identifying activity and partici­

Unruh and Henriksson. 2002). When attempting to

pation restrictions. Rath er, i t is equally important

understand the factors that may be causing or con­

for therapists to recognize what their patients can do.

tributing to activity/partiCipation restrictions, patients'

that is their activity and participation capabilities.

perspectives ( understandings. beliefs , feel ings) must

Where restrictions will often correlate with patients'

be considered and screened for. If a particular per­

goals. capabilities usually provide the point from where

spective has been hypothesized to be potentia l ly rele­

retraining or reactivation must commence. To attend

vant as an an tecedent to a patient's pain state, the

only to restrictions can be discouraging and cogni­

therapist must then. with the patient. endeavour to

tively behav iourally less effective in changing fu nction

u nderstand those factors in the patient's life that are

and performance. While procedural and comm u n ica­

responsible for. or have contributed to. the identified

tive management may specificaJly target identified

perspective. These may include such things as past

physical impairments and unhelpful perspectives,

and present negative personal experiences (e.g. abu­

respectively, facili tating fu nctional lifestyle imp rove­

sive relationships. conflicting or disempowering medical

ment requires retraining or recommencement of mean­

management) th at have contributed to shaping the

ingful activities (physical and social). If patients are only

patient's present beliefs, attributions and self-erficacy.

directed to those activities they can no longer perform. the result is often continued unsuccessful perform­ ance and fail ure. Therefore. management of specific

Pathobiological mechan isms

such as in adequate motor

Patients' activity and participation capabil ities/restric­

control, is commenced from postures or activities that

tions. aSSOCiated pers pectives/psyc hosoci a l problems

physical impairments,

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and specific physical impairments are an expression of their pathobiology and life circumstances. This hypoth­ esis category comprises data about tissue and pain mechanisms. It was designed to facilitate reasoning that would include consideration of the mechanisms by which the patient's symptoms and signs are being initiated and/or maintained by the nervous system.

Tissue mechanisms Tissue mechanisms relate to issues of tissue health and stages of tissue healing. In particular. how well the patient's presentation 'fits' with what would be expected during the corresponding stage of the normal tissue healing process (Gogia. 1992: Hardy. 1989: Vicenzino et aI., 2002) is integral in developing a hypothesis of the pain mechanisms at work. For exam­ ple, an inllammatory presentation in a disorder that has been present for months or years should elicit consideration of other factors (e.g. behavioural, bio­ mechanical, maladaptive central processing) that may be maintaining an inflammatory process or mimicking one through central sensitization.

Pain mechanisms Pain mechanisms refer to the different input. process­ ing and output mechanisms underlying the patients' activity/participation restrictions, unhelpful perspec­ tives and physical impairments. Input mechanisms include the sensory and cir­ culatory systems that inform the body about the envir­ onment. both internally and externally. Examples of two input pain mechanisms are nociceptive pain and peripheral neurogenic pain (Butler, 2000; Galea, 2002; Gifford. 1998d; Wright. 2002a). The basic mechanism operating when a high-intensity stimulus, such as a pinprick, activates high-threshold primary afferent nociceptors resulting in pain is well recognized. The same mechanism is in operation with acute injuries, where injury to target tissues, such as ligament, muscle or connective tissue surrounding nerves, will result in nociceptive pain. Peripherally neurogenic pain refers to symptoms that originate [rom neural tissue outside the dorsal horn or cervicotrigeminal nucleus, such as may occur with spinal nerve root compression or peripheral nerve entrapment. Both nociceptive pain and peripherally evoked neurogenic symptoms have a familiar pattern of presentation. with a predictable stimulus-response relationship, enabling consistent

aggravating and easing factors to be quickly identified by patient and therapist. Processing of input occurs in the CNS, and therap­ ists should be aware of the clinical features indicative of abnormal CNS processing. For example. abnormal processing can occur in patients displaying centrally evoked symptoms (Butler, 2000; Gifford. 1998e; Wright, 2002b), where the pathology lies within the CNS. Here the symptoms provoked from a past target tissue injury can be maintained even after the ori­ ginal injury has healed and the symptoms may no longer behave with stimulus-response predictability. Another example of the clinical relevance of the pro­ cessing mechanisms is evident when we consider that pain and disabUity have more than just physical and sensory dimensions (Merskey and Bogduk. 1994). Pain and activity/participation restrictions in all their forms also have affective (e.g. emotional impact such as fear, anxiety and anger) and cognitive (e.g. under­ standing , beliefs and attributions about the pain or disability) dimensions. Patients' feelings and thoughts about their pain and activity/participation restric­ tions can significantly contribute to the maintenance of their problems and influence the speed of the recovery (Butler, 2000; G ifford, 1998c; Main and Booker, 2000). While all pain can be exacerbated chemically by emotional and/or general physical stress, in a central pain state both physical and psychosocial stress are thought to be Significant contributing factors in maintaining the pain. Hence, a patient's perspectives, including their cognition (e.g. understanding of the problem and intervention required) and affect (e.g. feelings about the problem, management and effects on their life), are important dimensions of all pain states but are particularly significant in central pain. Ouput mechanisms operate through the motor, autonomic, neuroendocrine and immune systems (Butler. 2000; G ifford, 1998c). The somatic motor mechanism involves altered motor activity (increased or decreased) and movement patterns in response to pathology, but also learning. While painful pathology can inhibit muscle function and lead to altered move­ ment patterns (Hides and R ichardson, 2002) , many postural and movement abnormalities are associated with problems of motor learning as well as motor control (Shumway-Cook and Woollacott, 2001). These faulty movement patterns may be acquired through habitual postures and activities of life or may develop as a consequence of maintained pain.

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The au tonomic mechanism is a controversial output system in that features of abnormal sympa­ thetic activity are common in some chronic pain states. although the underlYing pathology is still u nclear. While the sympathetic nervous system is normally active in all pain states. it can be pathologically active in some. This pathological activity can contribute to disability. impairment and maintained pain (B utler. 2000; Gifford, 1998c: Wright. 2002b).

Other conseque nces of a stressed system The neuroendocrine system is responsible lor the regu­ lation of metabolism, water and salt balance, blood pressure, response to stress and sexual reproduction. Of these functions, its response to s tress is pHrticul arly relevant given that many patients have elements of stress that are a predisposing factor to. or lhe result of. their problems. Like the sympathetic nervous system. the neuroendocri ne system is responsive to our thou ghts and feeli ngs. Stress, for example. triggers a chain of events from the hypothalamus to the adrenal cortex that enables the appropriate channelling of energy for an individual to escape a perceived threat. However. maintained stress, as is common in so many chronic pain states, can result in mal­ adaptive neuroendocrine activity that is detrimental to tissue health and impedes tissue recovery (Butler. 2000: Giflord, 1998c: Martin, 199 7 ; Sapolsky, 1998). The neuroimmune system is an output system with close links to the brain. the sympathetic nervous system and the endocrine system. ChroniC pain, deconditioning or overconditioning and psycho­ logical impairment can interfere with normal immune and heali ng processes via this system (Butler, 2000: G ifford, 1998c: Mackinnon. 1999: Mar tin, 1997). The pathobiological mechanisms hypothesis cat­ egory is invaluable in focussing thinking to the devel­ opment of hypotheses about where within the nervous system symptoms are being produced and main­ tained, and what other sy stems rrtight be affected. If a patient presents with a 'normal' adaptive pain mech­ anism, wherein symptoms are the result of pathology of the implicated local tissues, it is appropriate to determine the precise physical impairment/diagnosis and identify a specillc site to direct manual treatment. However. when pain symptoms are the result of 'abnormal' maladaptive pain states, resulting from, and maintained by, altered CNS processi ng. manual

therapists must steer away from the sole usc of a lissue­ based paradigm and instead employ more holistic. less tissue-specific managemen t strategies. While physical impairments may still req uire attention, these patient presentations criticaJly require promotion of cognitive­ behavioural. healthlfitness and motor control change through adultltransformative lear ning. These issues are presented only briefly here: while there are numer­ ous basic pain science papers that support these con­ cepts. readers are referred to the excellent texts by Butler (2000). Gifford ( 1998f. 2000), Main and Spanswick (2000b) and Strong et aL (2002) for a more thorough review of pain mechanisms and associated strategies of management. Physical i m pai rments and associated structures/tissue so urces

A manual therapy diagnosis should be one that cap­ tures the therapist's understanding of the patient and the patient's problem(s). This would include the ther­ apist's judgment regarding each of the hypothesis categories discussed here. In our v iew, it is not satis­ factory simply to identify structures involved, as this alone does not provide sufficient information to understand the problem and its effect 011 the patient. nor is it sufficient to justify the course of management chosen. The manual therapy diagnosis must include a hierarchy of considerations from the activity/partic­ ipation restrictions, and any associated unhelpful perspectives or psychosocial problems, to specific physical impairments identified and their associated structure/tissue sources. Specific physical impairments in a musculoskeletal context are regional neuromusculoskeletal abnormal­ ities detected through the physical examination, such as lirrtited hip active movement, poor transversus abdominis motor control. or excessive glenohumeral joint mobility. The associated structure/tissue sources of physical impairments refers to the actual structure or target tissue from which the symptoms or signs are hypothesized to be emanating, with particular atten­ tion (where possible) to the pathology present within that str ucture. Joints. muscles. ligaments and even nerves are examples of target tissues that can be injured and give rise to pain and physical impairment. Clues to specifiC physical impairment sources are available from the area. description. behaviour and history of the sy mptoms. These hypotheses are then tested fur ther in the physical examination, where

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specific tests of structure and tissue impairment

by its potentia l effect on a specific structure. such as the intervertebral disc. the therapist can easily be mis­

are used . Interpretations regarding specilk sources of the

led i n attributing the improvemen t i n extension to a

symptomslimpairments must be made with reference

change in the disc sensitivity, structure or mechanics.

to the domimmt pain mechan ism(s) hypothesized.

This is. of course. an error of reasoning in that such

When nociceptive and peripheral neurogenic mech­

changes are only inferred.

anisms are dominant. local tissue impairment provides a more accurate

reflection of

the specific tissues

or more concern is that solely tissue-based reason­ ing tends to promote inflexibil i ty of management

involved . However. care is needed when processing

stra tegies. Our preference. like others (e.g. Maitland

mechanisms are dominant (i. e. maladaptive) as the

et ai . , 2001; Sarhma nn.

associated secondClry hyperalgesia ( CNS-maintained

tify potentially releva nt impairments and then hypoth­

200 2). is for therapists to iden­

Lissue sensitivity) can lead to false-positive cli nical f1nd­

esize about potential sources of those impairments.

ings (e.g. tender tissues. painful movements. etc.). which

Man agement is then directed to the impairment.

can then lead to incorrect conc l u sions rega rding the

\) \) � ). H. in

a l though this may include treatment to specific tissues.


This relates directly to the value of the disablemenl

centrClI pain stClte. t hese false posi t i ves are i n terpreted a s

model (Guide to Physical Therapy Practice. 2 0( H ) a nd

source of the symptoms (:l.usma n . I \) \) 7 . I implicating peripheral target t issues symptoms. interven tion strCltegies


a local source of

biopsychosocial model ( M a in and Spanswick. 2 ( ) ( ) ( )a:

m ay

then be i n appro­

Wadel ! .

pri ately applied to these target t i ssues. resu l t i n g i n poor

1\) \) � ) or c l i n ical practice.

whereby physicci l

treatment is guided by a c t i vity/par t i cipat ion rest r ic­

outcomes and possibly even contributing to the mainte­

tions and ident illed impairments Clnd not solely by diag­

nance of the problem ( Butler. 2( )OO; Watson. 2 0()O).

nostic labels ( M aitland et a l .. 20(H ). The application

Attempting to hypothesize about specific struc tures

of thorough assessmen t and balanced reasoning, in

such as contractile tissues. specific joints or neuro­

which identified impairments are considered in con­

gen ic pain is i mportClnt. and someLimes even critical

j u nction with known and hypothesized patho logy. wiU

in order to ensure safety (e.g. vcr tebrobasilar insuffi­

enable therapists to deliver effective treatments while

ciency. spinal cord pathology or joint instability).

continuing to improve understanding and to expand

However. in reali ty, it is often n o t possible to confirm

and. eventual ly. validate their clin ical impress ions.

c linically which specific tissues are at fa ult. Even with the assistance of advanced dia gnostic or imaging pro­ cedures where pathology can be demonstrated. con­

Contributi ng factors

firmation of those tissues as being the true source of

Contributing factors are any predisposing or associated

the symptoms is often impossible. Many degenerative

factors involved in the development or maintenance

changes evident on the various imaging procedures

of the patient's problem. These factors may be environ­

are asymptomatic and, therefore, may be minimally


relevant or even completely unrelated to the patient

chanical and even hereditary. For example. an inllamed

problem a t hand. It is not unusual for even the most

subacromial bursa may be the nociceptive source of the

skilful and experienced manual therapist to achieve

patient's symptoms and impaired movements. but com­




only a relative localization of the source of the symp­

monly either a tight posterior glenohumeral capsule

toms (e.g. lower cervical spine versus local shoulder

or 'vveak' scapular rotator force couples contribute to

tissues ) . even with a detailed evaluation and meticu­

altered kinematics that predispose the patient to bursal

lous reassessment of chosen interven tions. Therefore,

irritation. Similar ly, the source of the symptoms may

a balance is required in the specificity of hypotheses

be the CNS and the contributing factors might be the

generated regarding the source of the symptoms. The

patient's unhelpful perspectives (e.g. understanding.

therapist must recognize the limitations of such clin­

beliefs and feelin gs) . secondary to a combination of

ical diagnoses a n d take care to avoid limiting manage­

conflicting health-professional advice a n d in effective

ment only to proced ures directed to specific tissues.

coping strategies for a stressful work a n d family envi­

For example, while mobilization or exercise to improve

ron ment. The obvious importance of conSidering con­

an impairment in active lumbar extension can be

tributing factors relates to management options. Clearly

substantiated through reassessment of the extension

for many nociceptive dominant problems, treatment

impairment, when the same treatment is only j u stifted

directed to the actual impairment or source is helpful

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(e.g. mobilization for a stif r. painful movement or con­ trolled loading of a tendinopathy). In other cases, such as symptomatic hypermobile/unstable spinal or periph­ eral jOints , while some treatment in the form of pain­ relieving measures directed to the source of the symptoms may be indicated. the focus of treatment needs to address the contributing factors (e.g. retrain­ ing motor control or mobilization of adjacent areas of hypomobility to reduce the load on the symptomatic tissues). Ultimately, it is only through systematic reassessment of the management provided that the optimal balance of treatment directed to sources and contributing factors is determined. When maladaptive eNS processing is recognized as the dominant pain mechanism. management must be directed to the various patient perspectives. behaviours or physical impairments hypothesized to be contribut­ ing to the maintenance of their activity/participation restriction. However it is often difficult to be certain whether an apparent central sensitization is being driven by external contributing factors or whether sig­ nificant pain and physical impairment may. in fact. be contributing to the patient's stress and psychosocial problems. Again. reassessment is the manual therap­ ist's guide to malting this deCision. With a true noci­ ceptive problem , the signs and symptoms will improve , and continue to improve. in a predictable manner with time and/or skilled treatment. In contrast. when the patient's symptoms do not improve or maintain improvement from a trial of treatment directed toward a par ticular impairment or hypothesized nociceptive source. management must be redirected to the different contributing factors hypothesized to be maintaining the central sensitization (Kendall and Watson , 2000).

Precautions and contraindications to physical examination and treatment Hypotheses regarding precautions and contraindica­ tions to physical examination and treatment serve to determine the extent of physical examination that may safely be undertaken and whether physical treat­ ment is contraindicated or limited in any way by safety conSiderations. Such decisions are determined by consideration of many variables including: the dominant pain mechanism the patient's perspectives and expectations • the severity of the disorder • •

• • • • • •

the irritability of the disorder whether the disorder is progressive (and its rate of progression) the presence of specific pathology (e.g. rheumatoid arthritis. osteoporosis) the stage of healing general health the suspicion of more sinister pathology (e.g. unexplained weight loss).

If treatment is indicated. the therapist must decide whether any constraints to physical treatment exist (e.g. pain-provoking versus non-provocative treat­ ment techniques and the amount of force that can safely be used). A key examination strategy for identi­ fying potential risk factors is the use of screening questions directed to red flags , or clinical signs and symptoms suggestive of possible serious pathology. Redf/ags exist with respect to serious spinal pathology (Roberts , 2000). vertebrobasilar insuffiCiency (Barker et aI. , 2000; Di FabiO. 1 999; Rivett. 1997). certain paediatric disorders (e.g. slipped capital femoral epi­ physis). and the presence of non-musculoskeletal dis­ orders masquerading as musculoskeletal dysfunction (Boissenault. 1995; Goodman and Snyder. 2000).

Management relates to hypotheses regarding inter­ ventions for improving the overall health of the patient. as well as consideration of specific manual therapy measures and techniques. As with all hypothesis cat­ egories , management decisions should not be based on any single facet of the patient's presentation. Rather, information gleaned through the history and physicaJ examination. in addition to the patient's response to trial treatments, will collectively determine the pathobiological mechanisms. relevant iinpairments (and sometimes sources). contributing factors and the need for caution. Management decisions are then gUided via the weighting of evidence from each of these other hypothesis categories, with ongoing man­ agement informed through the reassessment process.

Prognosis Estimating patient responses and outcomes is predict­ ive reasoning (Edwards. 2001; Jones et al.. 2000). Manual therapists must be able to outline possible

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future scenarios based on consideration of the patient's presentation. responses to management interven­ tions and available evidence (clinically and research based). The likelihood of lhese scenarios eventuating depends on the nature of the patient's disorder and the patient's ability and wil lingness to make the neces­ sary changes to those factors contributing to the problem (e.g. physical. lifestyle. personal perspectives/ psychosocial). Prognosis should be considered with regard to the patient's broader prospects for recovery and return to function and/or the patient's potential for learning ' (e.g. changing beliefs and behaviours). which for some may include learning to live and cope with the problem. Like all clinical decision making. prognosis is an inexact science. with both positive and negative prognostic I"eatures typica lly being present in most patient's presentations. Factors that will assist in judging a patient's prognosis include: • •

• •

• • • •

the patient 's perspectives and expectations the patient's social, occupational and economic status the mechanisms of symptoms involved the balance of mechanical versus inflammatory components the irritability of the disorder the degree of damagelimpairment the length of history and progreSSion of the disorder the patient's general health and presence of pre­ existing disorders.

Psychosocial risk factors. or yellow flags (e.g. patients' beliefs/coping strategies. distresslillness behaviour. and willingness to change). should be screened for with all patients (Kendall et al. . 1 9 9 7 ; Main and Burton, 2000: Watson and Kendall. 2000). More recently, Main and colleagues (Main and Burton, 2 000: Main et al. . 2 000) have further delineated the occupational com­ ponent of the yellow flags into blue and b lack flags. BILle flags are derived out of the stress literature. They represent perceived features of work that are generally associated with higher rates of symptoms. ill-health and work loss and which may constitute a major obstacle to the patient's recovery. They are characterized by the follOWing features: • • • • •

high demand and low control unhelpful management style poor social support from colleagues perceived time pressure lack of job satisfaction.

Interestingly, a person's perception may be more sig­ nificant than any objective characteristics of the workplace. again highlighting the importance of psy­ chosocial screening in manual therapy assessment. Black flags include nationally established policy concerning conditions of employment and sickness policy, as well as the specific working conditions of a particular employer: •

national rates of pay - negotiated entitlements (benefit system . wage reimbursement) employer sickness policy restricted duties policy management style organization size and structure trade union support content-speci fic aspects of work ergono mic (e.g. job heaviness, lifting Irequency, postures) temporal characteristics (e.g. number of work­ ing hours. shift pattern).

Through the course of the patient examination and ongOing management. screening for red, yellow. blue and black flags. along with the physical examination and response to initial trial treatments. will assist the therapist in formulating a prognosis and determining the appropriate mode of management. Successfully obtaining this breadth and depth of information requires specific enquiries. For example, has the ther­ apist assumed or explicitly explored what the patient wants to do in the future? Further. with consideration of the patient's meaning perspective. is the patient's personal construction of their situation distorting their own view of what the future holds for them and thus distorting their decision making? Therapists must be adept with the various strategies of reasoning (e.g. diagnostic. narrative. collaborative) in order to achieve the necessary level of understanding required to make decisions effectively within each of the different hypothesis categories. The reflective therapist will not only weigh the full spectrum of prognostic variables in j udging a patient's prognOSis but also critical ly re-examine the j udgment when ongoing reassess­ ment reveals the projected prognosis is not being met. Often manual therapists' assessment and manage­ ment decisions require an element of ethical reason­ ing. The scope of ethical decisions faCing manual

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therapists can range from decisions regarding use of potentially aggravating or even life-threatening pro­ cedures to decisions of patient autonomy, informed con­ sent, confidentiality, interprofessional relationships, practitioner-client relationship , resource distribution/ cost containment and a myriad of day-to-day decisions that underpin quality care. Clinical decisions that are based solely on the therapist's judgment of what is best for the patient are not consistent with ethical decision making. Rather, decisions made for the client must be made with the client. We take the view that, as in other areas of decision making, competent man­ ual therapists should be guided by a combination or community and professional standards (e.g. profes­ sional association ethical guidelines) applied in a context-sensitive manner as learned through previ­ ous experiences. We are, therefore , in accord with Benner (1991. p. 18) who states, 'Ethics in health care must start with a practice-based understanding of what it is to be a person, what constitutes the rela­ tionships among the health care worker, patient, family, and community, and what constitutes care and responsibility toward one another'.

Summary Manual therapists must work with a multitude of patient and problem presentations, many of which defy simple technical solutions. Contemporary man­ ual therapy requires that therapists not only have a rich organization of clinically relevant biomedical and psychosocial (Le. biopsychosocial) knowledge but also have skills in diagnostic, narrative, collaborative, prog­ nostic and ethical reasoning. Successful application of that knowledge then requires advanced procedural

(e.g. manual techniques and motor control retraining) and communicative (listening, clarifying, explaining, negotiating and counselling) skills. Underpinning all dimensions of clinical reasoning is the abilily of therap­ ists to recognize relevant cues (behavioural, psycho­ logical, physical. social. cultural. environmental, etc. ) and their relationship to other cues, and to test or verify these clinical patterns through further exam­ ination and management. In this sense, clinical reasoning in manual therapy is hypothesis oriented. For all the various strategies manual therapists util­ ize in their patient management, perhaps the most pervasive are our skills in teaching. Reasoning related to teaching is enhanced when therapists understand concepts and strategies of learning theory, particu­ larly transformative learning, which aims to change individuals' meaning perspectives. How well practi­ tioners learn from the results of their decisions depends on the thoroughness of their deliberations and the time and attention given to their conscious rel1ection. There are no short cuts to becoming an expert manual therapist. However, it is our view that critical, rel1ective and collaborative reasoning will improve the breadth and depth of clinical patterns (regarding the person and the problem, including management strategies) that can be recognized and applied. It has been estimated that master chess play­ ers have some 50 000 configurations of chess that they can recognize (Posner. 1988). While the breadth of clinical patterns that experts such as those repre­ sented in this book possess has not been calculated, it is reasonable to assume their organization of clin­ ically relevant knowledge would be equally stagger­ ing. It is our opinion that expertise is not acquired by experience alone. Rather. expertise is developed, in part, through skilled rel1ective reasoning.

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Schmidt. H . G . a n d Boshuizen. H . P A . ( 1 9 9 3 ). On acquiring expertise i n medicine. Educational Psychology Review. 5 , 2 0 5-22 l . Schmidt. H.G . . Boshuizen. H.P.A. and Norman. G.R. (J 9 9 2 ) . Rellections on the nature of expertise in medicine. [n Deep ModeIs for Medical Knowledge Engineering (E. Keravnou. ed.) pp. 2 3 1-248. Amsterdam: Elsevier Science. Schmidt. H.G .. Norman. G . R . and B os h u izen. H . P. A . ( 1 9 9 0 ) . A cognitive perspcctive on mediCal expertise: theory and implications. Academic Medicine. 6 5 . 6 1 1-6 2 1 . Schon. D. A. ( 1 9 8 3 ) . The Reflective Practitioner: How Professionals Think i n Action. London: Temple Smith. Schon. D. A. ( 1 9 8 7) . Educa ting the Rellective Practitioner. San francisco. CA: jossey-Bass. Shendell -Falik. N. ( 1 990). Creating seJf­ care u n its in the acute care setting: a case study. Patient Education and Counselling. I S . 39-4 5 . Shepard. K . E a n d Jensen. G . M . ( 1 9 9 0 ) . Physical therapist curricula for the 1 9 90s: educating the rellective practi­ tioner. Physical Therapy. 70. 5 6 6-5 7 7 . Shu mway-Cook. A. a n d Wool l acott. NUl . ( 2 00 1 ). Motor Control: Theory and Practical Applications. 2nd ed n. Bal timore. M D : Lippincott. Williams & Wilkins. Sluijs. E.M. ( 1 9 9 1 ). Patient education in physiotherapy: towards a planned approach. Physiotherapy. 77. 503-5 0 8 . Strong. J . ( 1 9 9 5 ) . Sel l�erficacy and the patient with chronic pain. In Moving i n on Pa in ( M . Shacldock. ed . ) pp. 9 7- 1 0 2 . Chatswood: Bu tterwort.h-Heinemann. Strong. J . . Unruh. I\.. M . . Wright. A. and Baxter. G.D. (eds.) ( 2 0 0 2 ) . Pain. A Textbook for Therapists. Edi nburgh: Churchi l l Livingstone. Tulving. E. a nd Thomson. D.M . ( 1 9 7 3 ) . Encoding specificity a n d retrieval processes in episodic memory. Journal of Psychological Review. 80. 3 5 2-3 7 3 . U n r u h . A . M . a n d Henriksson. C. ( 2 0 0 2 ) . Psychologica l . environ mental and behavioural dimensions of the pain experience. In Pain. A Textbook for Therapists O. Strong. A . M . Unruh.

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BiopsychosociaJ Assessment. Relationships and Pain (L. Gifford. ed ) pp. 1 1 1 -1 2 9 . Falmouth. UK: CNS Press. World Health Organization (200 1 ) . ICF Checklist Version 2 . 1 a. Cli n ician Form for International Classification of Functioning. Disability and Health. Geneva: WHO. [Ava ilable online at http://ww w. who.inticiassifIcation/icfl checklist/icf-checkl ist.pdf. April 1 5 . 2002.] Wright. !\. (2002a). Neuropatbic pain. In Pai n . A Textbook for Therapists (J. Strong. A . M . Unruh. A. Wright. and G . D. Baxter. ed s.) pp. 3 5 1- 3 7 7 . Edinburgh: Churchill Liv ingstone. Wright. A. ( 2 002b ) . Neurophysiology of pain and pain mod ula tion . In Pa in.

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A Textbook for Therapists (J. Strong. A.M. Unruh. A. Wright. and G.D. Baxter. eds.) pp. 4 3-64. Edinburgh: Churchill Livingstone. Zusman. M . ( 1 9 9 7 ) . Instigators of activity intoleronce. Manual Therapy. 2. 75-8 6 . Zusman. M . ( 1 9 9 8 ) . Structu re-oriented beliefs and disability due to back pai n. Austra l ian Journal of Physiotherapy. 44. 1 3-20.

Clinical reasoning in action: case studies from expert manual therapists II II

Back and bilateral leg pain in a 63-year-old woman


Ongoing low back, leg and thorax troubles, with tennis elbow and headache


Chronic low back pain over 13 years




Dick Erhard and Brian Egloff

Unnecessary fear avoidance and physical incapacity in a 55-year-old housewife

A chronic case of mechanic's elbow




Toby Hall and Brian Mulligan

Chronic low back and coccygeal pain


Paul Hodges

Ankle sprain in a 14-year-old girl



Gary Hunt

Headache in a mature athlete


motor vehicle accident


Erl Pettman

A judge's fractured radius with metal fixation following an accident


A university student with chronic facial pain


Mariano Rocabado

Adolescent hip pain


Shirley Sahrmann

A software programmer and sportsman with low back pain and sciatica


An elderly woman 'trapped within her own home' by groin pain

work and sport


Patricia Trott and Geoffrey Maitland

Thoracic pain limiting a patient's secretarial 149

Chronic peripartum pelvic pain

Diane Lee


John van der Meij, Andry Vleeming and Jan Mens

Bilateral shoulder pain in a 16-year-old long-distance swimmer


Medial collateral ligament repair in a professional ice hockey player

Patellofemoral pain in a professional 194

ED Ell

Acute on chronic low back pain



Richard Walsh and Stanley Paris

A non-musculoskeletal disorder masquerading as a musculoskeletal disorder


David Magee

Jenny McConnell

Craniovertebral dysfunction following a

Tom Arild Torstensen

Gwendolen Jull

tennis player


Robin McKenzie and Helen Clare

Robert Pfund in collaboration with Freddy Ka/tenborn

Louis Gifford

Mary Magarey


Self-management guided by directional preference and centralization in a patient with low back and leg pain

Mark Bookhout

David Butler




Peter E. Wells

Forearm pain preventing leisure activities


Israel Zvulun

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Back and bilateral leg pain in a 63-year-old woman Mark Bookhout


A 63-year-old retired female (Francis) presented to our clinic with a chief complaint of low back pain and bilateral lower extremity pain. She had led an active lifestyle and was happily married. with her husband in good health. She played tennis. travelled and was taking computer classes. Francis gave a history of low back pain, chronic in nature, resulting from a lifting injury 22 years previ­ ously. At the time of her original inj ury, she was d iag­ nosed by an orthopaedic surgeon as having a herniated lower lumbar disc, but she was unaware of the actual level of herniation. Francis reportedly had been able to self-manage fairly well with intermittent low back pain until her most recent episode, which commenced approximately 4 months before her first consultation with me. At that time. s he developed sharp shooting pains into both of her lower extremities without any apparent trauma or predisposing factors that she could recaU, otber than the fact her symptoms were exacer­ bated by playing tennis. Francis also noted an increase in her low back pain but reported that her leg pain was more severe and d isturbing to her because she had not had any leg symptoms previously. The pain was described as radiating down into the bu ttocks and the posterior legs as far as the calves and heels, but not into the reet. seemingly following an LS or Sl dermatomal distri.bution. Francis was seen by a physician, who ordered an enhanced computed tomography (CT) scan of the lum­ bar spine with myelography. The scan revealed central spinal canal stenosis along with mUltiple level lumbar

degenerative disc disease and a grade I spondylolisthe­ sis at LS-S1. Francis then had an epidural steroid injec­ tion (4 months ago), which gave her some relief with a notable decrease in pain intenSity, but the distribution of the referred pain was unchanged. She reported the pain had been relieved approximately 40-50% by the epidural injection. Subsequently she was placed on an anti-inllammatory medication (nabumetone). which she was still taking when therapy was initiated . Francis reported that the medication helped her quite a lot. decreasing the intensity of her pain by another 20%. She had not received any previous physical therapy treatment ror her condition and she was self-referred. A physician had apparently told her that she might be a surgical candidate and her primary goal in seeking physical therapy treatment was to avoid having lumbar spine surgery if at all possible and to be able to continue to play tennis, her main passion in life. Francis reported that her back pain was aggravated by slow wa lking, prolonged standing greater than 1 hour. playing tennis and bending slightly forward as in doing her dishes or vacuuming. She reported that her leg pain was specifically accentuated during and after playing tennis, and she could only play 15-20 minutes before noting a significant onset of leg pain. Sleeping was reportedly not a problem and neither was sitting, but lifting heavy loads aggravated her back pain. Coughing and sneezing had no effect on her symptoms. Overall, she rated her level or pain at 4110 but it could l1uctuate from 0/10 on a good day to 5/10 on a bad day.

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The medical history was otherwise unremarkable.

many years previously and had also been hospitalized

There was no paraesthesia and no reported subjective

for an automobile accident with facial injuries at

numbness. She denied any bowel or bladder problems

17 years of age. but there were no reported residual

or any history of trauma. Francis also denied any

problems. Francis was particularly distressed about

recent weight gain or loss and her medical history

her inability to play tennis without pain and was

was negative for high blood pressure, tuberculosis,

somewhat fearful of the possibility of lumbar surgery,

anaemia, cancer, heart problems, depression, thyroid

which she strongly wanted to avoid. There did not

problems, emphysema. hepatitis, asthma, kidney dis­

appear to be any other

ease or diabetes. She had had one epileptic seizure


significant psychosocial



Please comment on the range of hypotheses you

jOints and sacroiliac joint were noted, I felt that her

had at this stage regarding possible sources of

dominant pain mechanism was probably nociceptive

her symptoms. Which of these did you think was

arising from faulty and dysfunctional joint mechan­

most likely and what was the pattern within the

ics. I did not find evidence to support involvement of

subjective examination that supported this

any pathological central pain mechanisms or dys­ function within the output systems (i.e. sympathetic,

principal hypothesis!

endocrine, immune, motor).

• Clinician's answer

Please discuss your reasoning with respect to

I felt that the patient had several possible sources for

likely contributing factors to this most recent

her symptoms, including central or bilateral lateral

episode of symptoms.

foraminal stenosis at LS-S1 (with associated neuro­ genic claudication), secondary to spondylolisthesis at LS-Sl, and/or dynamic instability at LS-S1 secondary

• Clinician's answer

to lumbar degenerative disc disease. I also thought

r felt that the most likely contributing factors to this

that mechanical dysfunction of the lower lumbar

recent episode of symptoms were the patient's age,

facet joints could result in the described pain referral

the IU<ely weaknesslineffectiveness of her core trunk

pattern into the lower extremities. r initially believed

muscular stabilizers and stiffness of the facet joints,

that the primary source was most likely dynamic

all combined with continued aclivity (i.e. playing ten­

lumbar instability at LS-S1 since in her subjective

nis on a regular basis) that her spine (structurally and

history she reported an accentuation of her symptoms

dynamically) was unable to cope with.

with activity (particularly the leg pain), especially with playing tennis.



Were there any features within her subjective examination that signalled the need for caution

Did you have any reason at this stage to suspect

in your phYSical examination and treatment!

involvement of 'pathological' central pain mechanisms in her presentation! Please briefly discuss your thoughts on the dominant pain mechanisms you hypothesized were evident from her presentation thus far.

Clinician's answer There were no features within the subjective exam­ ination that signalled the need for caution or impli­ cated any contraindications to my examination or treatment. Her disorder seemed to present as having a

Clinician's answer

low irritability level with no significant neurological

After my objective clinical examination in which sig­

flDdings anel certainly no progressive neurological

nilkant joint restrictions in the lower lumbar facet


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Clinical reasoning commentary

The clinician's answers to these questions reflect the breadth or his reasoning through the subjective examinatioll, Importantly, he does not simply accept what the patient spontaneously ofl'ers further by screening for other types of symptom, aggravating factors and general health considenl­ tions. j\llulliple structures are considered as possibly being responsible lix the patient's symptoms and these are .directly linked to associated structural


(e.g. spondylolisthesis) and dynamic (e.g. core trunk muscular stabilizers) contributing factors. Similarly, the clinician's consideration of potential contribut­ ing factors is broad in scope, ranging from the patient's age (and associated degenerative state of her spine) to the stability and mobility of her spine. Her lifestyle. in this case her activity level and pas­ sion for tennis, are also included, providing a num­ ber of options with respect to management Hnd an awareness of the patient's personal goals.


Francis was evaluated from a biomechanical perspec­ tive because she was found to be neuro[ogically intact, demonstrating no subjective or objective numbness or sensory deficits and no motor weakness in the [ower extremities. Rellexes were not tested. She presented with a mesomorphic body build and was right handed. Standing

In standing, a hyperlordosis with a palpable step at the L4-L5 segmental level was evident. There was banding of the musculature across the lower lumbar spine and an apparent flattening of the lumbosacral junction. Forward flexion mobility was full range (fin­ gertips touching toes) and without pain provocation, but the standing forward bending test for the sacro­ iliac jOint was positive on the right side. The one-legged stork test, another sacroiliac joint screening test, was also posiLive on the right side. Both the forward bend­ ing test and the one-legged stork test are screening tests for possible involvement of the sacroiliac joint but are non-specific for any particular dysfunction. During the forward bending test. the right posterior superior iliac spine (PSIS) travelled further than the left; with the one-legged stork test on the right side, the right PSIS moved superiorly rather than inferiorly when the patient lifted the right knee up towards the chest. Both of these findings indicated resLTicted mobil­ ity of the right sacroiliac jOint (Bourdillion et al.. 1992; Greenman, 1996; Isaacs and Bookhout, 2001). Lumbar side bending range of motion appeared to be within normal limits, both symmetrical and painless, w:ith normal pelvic coupling noted dnring side bending to either side. The hip drop test, which is a test for side

bending of the lower lumbar spine. appeared, however. to be restricted on the right side. The test is performed by having the standing patient bend one knee and allow the pelvis to drop. Thus, if the right knee is bent the pelvis drops on the right side, invoking left side bending at L5-S1. The test can also be used to indicate whether or not the sacral base anteriorly nutates on the side of the hip drop. so the test is not speCific for any dysfunc­ tion but is again a general screening tool (Jsaacs and Bookhout. 2001). Lumbar extension was not pain provocative but was significantly restricted at the lum­ bosacral junction. with most of the extension move­ ment appearing to occur in the upper lumbar spine. Sitting

In sitting, the forward bending test appeared to be positive on the right side. With this test, the operator palpates each PSIS with their thumbs and the patient is asked to bend forward. The operator's thumbs follow the PSISs throughout the range of forward bending. In this case. the right PSIS moved superiorly and anteri­ orly further than the left, indicating resLTicted jOint play motion on the right side. This test is an additional screening test for sacroiliac joint dysfunction but is also non-specific (Bourdillion et aI., 1992; Greenman, 1996; Isaacs and Bookhout. 2001). Palpation of the inferior lateral angle (ILA) of the sacrum with the patient in a fully flexed lumbar position revealed asymmetry with the left ILA posterior and inferior. Positional testing of the lumbar spine in full l1exion revealed no asymmetry of the lTansverse processes from approxin1ate[y L2 to L5, but there was asymmetry at L1. which appeared to be rotated to the right.

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Active trunk rotation in sitting appeared to be sym­ metrical bilaterally with no pain provocation. Supine In supine lying, the passive range of motion of the lower extremities revealed a restriction for combined movements of hip flexion, adduction and internal rotation on the right side compared with the left. The patient complained of 'pinching' in the anterior hip and groin on the right side du ring these combined hip movements. Passive straight leg raising was to 80 degrees bil aterally without pain provocation. Palpation of the pubic symphysis revealed an inferior pube on the right side, with significant tenderness to palpation of the right inguinal ligament. Palpation of the lower abdominal quadrant revealed a marked increase in tone and tenderness of the psoas and iliacus muscula ture on the right side. Anterior to posterior translation of the innominates revealed a restriction on the right side compared with the left. There was also a loss of anterior to posterior glide of the right hip joint relative to the left jOint. Ac tive heel slide in supine lying revealed a significant imbalance i n muscle control on the right side versus the left, with Francis unable to maintain a neutral spine on the right side while performing an active right heel slide through full range without the innominate rotating an teriorly. This test is thought to indicate an imbalance between the abdominal and hip flexor musculature, in this case on the right side (Bourdillion et ai., 1992; Greenman. 1996; Isaacs and Bookhout . 2 001). Prone In prone lying, the leg lengths appeared to be symmet­ rical. as did the ischial tuberosity heights. There was some increase in tension noted on palpation of the right sacrotuberous ligament and there was significant tight­ ness and tenderness noted on palpation of the right long dorsal sacroiliac ligament. The long dorsal sacroiliac lig­ ament is thought to become taut with posterior nuta­ tion of the sacral base (Vleerning et aI., 1996). Palpation of the ILAs of the sacrum revealed the left ILA to be pos­ terior and inferior. Passive mobility testing of the sacro­ iliac joints i n prone lying indicated a loss of anterior nutational movement of the right sacral base. Positional testing of the lumbar spine in a prone prop position, where the patient supports their head and chin on their hands while propped up on their elbows, revealed that


Fle xi on

Fig. 2.1

Le ft

Ri ght



Pi ct ogra m i llustrati n g an FRS ri ght , a p ositi onal

dia gn osis for a spin al se gment that is held in a fle xed , ri ght rotated and ri ght-side bent p ositi on . This s hows the res p ons e of the transverse p r ocesses (TP) w hen there is an ina bili ty for the l e ft fa cet j oint to cl ose . N ote h ow the TPs appear asy m m etri cal (i.e. r ota ted to t he ri ght in e xtensi on but n ot in flexi on ).

the transverse processes of L5 were asymmetrical. with the right transverse process of L5 being posterior when compared with the left transverse process and the sacral base below. This positional finding is indicative of a loss of the combined movements of extension, left-side bend­ ing and left rotation at L5-S1, secondary to the inabili ty to close the left facet jOint at L5-S1 (Fig. 2 . 1 ). There was also asymmetry of the transverse processes of 14 found with positional testing in prone on elbows. The left transverse process of L4 appeared to be posterior when compared wHh the right transverse process and L5 below. This positional fmding is indicative of an inabil . i t to close the right facet joint at L4-L5, with a loss of mobility for the combined movements of extension, right-side bending and right rotation. Passive accessory intervertebral mobility testing with unilateral posterior to anterior pressures on the right transverse processes from L1 to Sl produced sig­ nificant local pain at L4 and Sl. Positional testing and passive accessory intervertebral mobility testing of the thoracolumbar j unction revealed an FRS right (spinal segment that is held in a flexed, right rotated and right-side bent position) at approximately Tll-Tl2 , with a loss of the combined movements of extension, left-side bending and left rotation. Active hip exten­ sion in prone lying was restricted by over 5 0%, li mited

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to less than 10 degrees in range bilaterally, with

right. It was felt that this loss of hip extension was

apparent reduction in tone (inhibition) noted on

a consequence of tight hip l1exors (on the right side

palpation of the gluteus maximus, especially on the

greater than the left), in particular the iliopsoas,



Please briefly summarize your reasoning at this

The patient also had a positive right hip drop test.

point with respect to your hypotheses regarding

indicative of impaired coupling at L5-S1 with a loss of

the principal sources and contributing factors of

left-side bending at L5-S1 and/or a loss of anterior

these symptoms.

nutational movement of the right sacral base. Palpation of the ILAs. both in forward l1exion and in the prone

• Clinician's answer

extended position , revealed asymmetry. with the left

My initial assessment was that of chronic low back pain and bilateral leg pain initiated by an initial injury

22 years earlier: there was now significant mechanical dysfunction of the lower lumbar facet joints and right sacroiliac joint. along with

LS-Sl grade I spondy­ lolisthesis and lateral spinal stenosis at LS-Sl. Francis em

presented with marked mechanical dysfunction involv­ ing the right sacroiliac joint. as well as mechanical dysfunction at L4-LS and LS-Sl. which I [elt was responsible for the referred pain folJowing an L5-S1 distribution in her legs, The patient had significaot hypertoniCity and resultant tightness in the iliopsoas muscuJature bilaterally, greater on the right side than the left. I"vith Limitation 0[' active hip extension mobility as well as inhibition of gluteus maximus musculature,

ILA being posterior and inferior; this is indicative of

either a structural anomaly or a sacroiliac dysfunction. Passive mobility testing of the sacroiliac joints revealed a loss of anterior nutation of the right sacral base. con­ firming a right sacroiliac joint impairment. The patient also had a positive iliac shear test on the right side. demonstrated by a loss of anteroposterior translation of the right innominate. Palpation of the pubic tubercles revealed an inferior pube on the right with tenderness of the right inguinal ligament. Palpation also revealed significant tightness and tenderness of the long dorsal sacroiliac ligament on the right side versus the left. The loog dorsal sacroiliac ligament became taut and tender in the presence of a posterioriy nutated sacral base (i.e. loss of anterior nutatiooal movement).

especialJy the right. She appeared to have no neuro­ logical involvement, although she was not assessed for adverse neural tension signs other than straight leg raising, which was to 80 degrees and pain-free at the initial visit. There also appeared to be limitations in mobility of the right hip, with loss of the combined movements of hip flexion, adduction and internal rota­ tion, possibly secondary to lumbar and pelvic dysfunc­ tion or secondary to a tight posterior right hip capsule.


• Clinical reasoning commentary What should be evident throughout the clinician's physical examination and reasoning is the specilk nature of his hypothesis testing. That is. hypothe­ ses regarding possible sources and contributing factors formulated during the subjective examina­ tion are specifically tested through the phYSical examination. The physical impairments identified include impairments of spinal. sacroiliac and hip

Please elaborate on your analysis of the

joint mobility, soft tissue/muscle shortening, and

sacroiliac joint impairment.

increased muscle tone and poor motor control. Nevertheless. the character of the clinician's sum­

Clinician's answer

mary of I1ndings rellects an open mind. Identified

I felt that sacroiliac jOint impairment was evidenced by

impairments are presented as an 'initial assess­

several key t1ndings during the screening examination.

ment', consistent with the subjective presentation.

The patient had a positive forward bending test on

The impairments identilied represent treatment

the right side. both in standing and in sitting. and a

options that. through intervention and reassess­

positive one-legged stork test on the right side as well.

ment, will ultimately establish their relevance,

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r explained my clinical findings to Francis and my rec­

ommendations for treatment. She initially understood her treating diagnosis to be mechanical low back pain with a n L 5-S 1 spondylolisthesis and lateral spinal stenosis a t L 5 -Sl. I did not feel there were any con­ traindications to physical therapy intervention and so she was scheduled to see me initially for eight treat­ ment sessions over a 30-day period. Francis and I jointly agreed her goals for treatment would be for her to be able to play tennis without provoking back or leg pain, and to be able to control her symptoms with a home exercise programme and with decreased usage of her pain medication (nabumetone). We also set another functional goal for her, which was to be able to tolerate standing on her feet for prolonged periods or time, up to 1 to 2 hours. without leg pain. such as when window shopping. washing the dishes and hoov­ ering. I anticipated that these functional goals would take approximately 1 month to ach ieve and that the prognosis for improvement and accomplishment of these goals was good to excellent. Following the evaluation, treatment was initiated and consisted of muscle energy tech niq ues to treat an FRS right at L 5 -S1 and an FRS left at L4-L 5 . so as to restore extension mobility from L4 to Sl. For both of lhese techniques. Francis was treated ly ing on her side. specifically localizing forces first to L5-S1 and then to L4-L 5, with extension from above down and from below up combined with the appropriate side bending and rotation (Fig. 2 . 2). Francis was asked speciftcally to work primarily with an active side-bending effort using the leg as a long lever, followed by post-isometric relax­ ation to increase side bending and extension of the spinal segment. I directly mobilized the sacroiliac joint u tilizing a technique to treat a unilateral posterioriy

Fig. 2.2

Mus cle ener gy te chnique for corre ctio n of a FRS

ri ght (s p i n al se gme nt that is hel d in a fl e xed , right rotated and ri ght-s ide be nt position ) at LS-S 1 .

nutated sacrum on the right to improve anterior nutation of the right sacral base (BourdiJJion et al . . 1 9 92; Green man. 1 9 96; Isaacs and Bookhout. 200l). The inferior pube on the light side was also treated with muscle energy techniques. by resisting active hip extension and then upon relaxation correcting the inferior pube by pressing the ischial tuberosity in a superior and medial direction. The reader is referred to Greenman ( 1 9 96) and Isaacs and Bookhout (200 1 ) for further detail of these techniques. Francis received deep soft tissue mobilization to the iliopsoas muscula­ tu re. especially on the right side, followed by instruc­ tion in kneeling hip nexor stretching and prone transversus abdominis retraining to practise at home. Specifically, I attempted to re-educate and balance the musculature on the right side of the pelvis, based upon her initial inability to perform a supine heel slide on the right side without anteriorly rotating the innominate.



What were the key features in this presentation that you recognized


indicating a good prognosis!

• Clinician's answer I felt Francis had a good prognosis based upon the fact

that she had a specific goal in mind for treatment (Le. returning to playing tennis). She also had good gen­ eral health habits, appeared to have no psychosocial

factors. and she appeared to have speci11c mechanical jOint restrictions that I felt were d irectly related to her symptoms and clinical presentation .


Mutually agreed formal goal setting is clearly a key feature of your management. Could you briefly hi ghlight your views on the significance of mutual goal setting!

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• Clinician's answer I place considerable value on mutual goal setting to establish good communication between myself and the patient. I believe this is an essen tial component of the first initial visit. to make sure that the patient and I have the same expectations to measure the effective­ ness of treatment. If mutual goal setting is not done at the onset of treatment, the patient may have a different goal from that of the therapist. with the patient and therapist measuring the success or failure of treatment from two different perspectives (Le. the patient's goal is total pain relief while the therapist's goal is increased tolerance for sitting, walkin g, other activities in daily living). This can create a sense of disappointment over the course of treatment if the patient feels his or her needs are not being met despite 'objective' improvement noted by the treating therapist.

Clinical reasoning commentary

key dimension of clinical reasoning evident in the clinician's philosophy of management is his collabo­ rative approach with the patient. As discllssed in Chapter 1. patients begin their encounter with a man­ ual therapist with their own ideas of and feelings about the nature of their problems and the manage­ ment they want. as shaped by personal experiences and advice from medical practitioners. family and A

On a subsequent visit. latissimlls dorsi sel f-stretching was added as Francis appeared to be Significantly tight on the right side. The latissimus dorsi was found to be tight by assessing bilateral shoulder flexion in supine lying with the lumbar lordosis eliminated. The latissimus dorsi was s tTetched using the technique described by Evjenth (Evjenth and Hamberg. 1 984) to decrease stress at the lumbosacral j u nction. After the fifth visit, and approximately 2 weeks into treatment, Francis reported she was able to play tennis without leg pain and had noted a substantial diminution in her need for pain medication. decreasing her dosage

Fig. 2.3

Muscle energy technique for stretching the hip

flexors on the left side.

friends. For some patients. their meaning perspectives (understanding/beliefs. aUiLudcs. emotions and expectations) are distorted and counterproductive to their recovery. Successful patient management is opti­ mized when therapists attend to the patient's perspec­ tive and include the patient in the decision making. The clinician's explanation of I1ndings and philoso­ phy of involving the patient in setting treatment goals exemplify this collaborative approach to reasoning.

by over half. The hips were then treated, utilizing muscle energy techniques to lengthen the iliopsoas. tensor fascia latae and hip external rotator muscula­ ture, These muscle groups were stretched in prone lying with the opposite leg off the end of the table and supported on the floor (Fig. 2 . 3 ) . In addition. the hips were mobilized in a posterior to anterior direction to improve both active and passive hip extension mobil­ ity. Piriformis self-stretching in supine lying was added to her home exercise programme. along with gluteus maximus retraining while maintaining a neutral lumbar spine with transversus abdominis activation.

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REA SONING DISCUS SION AND CLINICAL REA SONING COMMENTA RY Please discuss briefly your philosophy of reassessment, providing examples of how in this case reassessment was used to determine the

provoking, in this case rotation in standing (e.g. as in playing tennis).

effect of any given treatment procedure.

Clinical reasoning commentary

• Clinician's answer At each visit. I reassessed the major clinical findings, which included mobility for extension at L4-L5 and L5-S l, as well as mobility of the right sacroiliac j oint. I also monitored recruitment of the right gluteus maximus and tranversus abdominis musculature and I reassessed the right hip for combined movements of flexion, adduction a nd internal rotation. My expect­ ation was to find improvements in jOint mobility at L4-L5 and L5-S l , as weI! as mobi lity of the right hip and right sacroili�c joint from one treatment session to the next. I attempted to correlate improvements in joint mobility with improvements in function a l performance by asking t h e patient to show active movement (Le. extend the h i p, recheck the forward bending and one-legged stork tests, and recheck the right hip drop test). I feel it is important to show the patient (as well as to remind the patient) of how their original findings have changed , since often a change in movement/mobility, both actively and passively, occurs before the patient's symptoms improve, espe­ Cially in patients with chronic pain.


You have described attempting to re-educate the balance of this patient's lumbopelvic musculature, highlighting examples of training in supine and prone lying. Was it necessary for the patient to progress this retraining to other positions!

• Clinician's answer Although not directly discussed in this case, I gener­ aJly progress patients from non-weight-bearing exercises to weight-bearing exercises and activities, incorporating the patient's exercise programme into functional activities and activities of daily living. I believe this is especially important in retraining muscular control , especially retraining for activities that previously were reported by the patient as pain

For skilled manual therapists, reassessment is sec­ ond nature. However, it is important to recognize reassessment as a form of hypothesis testing by which the therapist's understanding of the problem and the person is either supported or not supported. and management continued or altered accordingly. The breadth and specificity of reassessmcnt will vary according to the nature of the problem alld the pain mechanism j udged to be dominant. In any case. care is needed when hypotheses regarding t he 'source' or pathology are tested through reassessment. Clearly an improvement. in mobility. muscle control or pain response does not conlirm a source or pathology. For t hat. more sophisticated assessment/reasscssment through advunced imaging procedures. electromyo­ graphy or other medical investigations arc needcd, many of which themselves have poor predictive validity. We encourage therapists to hypothesize about specilk structu re/tissue sources and to con­ sider the nature of the pathology, as these deli­ berations will assist therapists' search for a better wlderstanding of the relationship between palllol­ ogy. pain and physicul impairment. However, to avoid misleading yourself that you have c1Tected a change in the pathology or structure of a specific tis­ sue, it is better to view your treatments. as the clini­ cian has here. as being directed t oward a specific impairment (physical or psychological) in order to establish the relevance of the identified impairment to the patient's presentat ion . Encouraging patient understanding. which may require modil1cation to their pre-existing per­ spectives, is an ongoing feature of manual t herapy management. Even subtle strategies, as the clini­ cian has alluded to here when pointing out to the patient changes in the impairment. contribute to improved patient understanding. As discussed in Chapter 1, improved understanding fosters greater self-efllcacy/responsibility and patient participa­ tion in management.

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Outcome Francis received 11 treatments over the course of 2 months. When seen for her last appointment. she reported that she was doing extremely well. was no longer taking any pain medication. and no tably had no leg pain complaints even after playing tennis for 1. 5 hours. She had intermittent mild low back pain that she reported was not limiting her activities of daily l iving at all. Francis felt that her exercise pro­ gramme gave her significant control of her symp­ toms. and she now rated her low back pain as 2110 compared with 4/10 initially. Her mechanical find­ ings were reassessed and compared with the i nitial evaluation. She had regained full and pain-free range of motion of the right hip for f1exion. adduction and

internal rotation and showed significant improve­ ment in anterior nutational movement of the right sacroiliac joint. Positional and passive mobility test­ ing of the l umbar spine revealed improved mobili.ty at L4-LS. with only slight restriction on the right side at LS, which was treated on her last visit with unilateral posterior to anterior grade IV pressures (Maitlan d , 19 86) . She now was better able t o recruit t h e gluteus maximus on the right side d uring active right hip extension i n prone lying. and her hip extension range of motion had notably improved, with the ability to extend the hip 10-15 degrees from the prone lying position bilaterally. Francis was discharged from physical therapy 2 months after initiating treatment and instructed to call should she have any further questions or problems in the future.

References Bourdillon. J,F.. Day. E.A. and Bookhout.


PE. (1996). Principles of

M.R. (1992). Spinal Manipulation.

Manual Medicine. 2nd edn.

5th edn. Oxford: Butterworlh­

Baltimore. MD: Williams &



E\ljenth. O. and Hamberg. J. (1984).


Maitland. G.D. (1986). Vertebral Manipulation. 5th edn. London: Butterworth. Vleeming.

E.R. aod Bookhout. M.R. (2001).

Hmnmudughlu. B. et al. (1996). The

Muscle Stretching ami Manual

Bourdilloo's Spinal Manipulation.

function of the long dorsal sacroiliac

Therapy. A Clinical Manual. Vol. 1.

6th edn. Woburn. MA:

ligament. its implication for understand­

Alfta. Sweden: Alfta Rehab.

Bu tterworth-Heinemann.

ing low back pain. Spine. 21.556-562.

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Ongoing low back, leg and thorax trou bles, with tennis elbow and headache David Butler


During my c l inical career, I can recall four particular patients who stand out as prod ucing significant changes i n my understanding of clinical presenta­ tions and my professional direction. The patient described here, with ongoing low back, leg and thorax troubles, plus tennis elbow and headache, is the most recent. Ru by. a 5 2 -year-old sligh tly overweight European woman with a sparkle in her eyes was referred via a physicia n to ascertain the value of continuing physio­ therapy treatment for o ngoing back pain. I noticed immediately that she had little trouble getting up the two llights of stairs in our practice. and when I intro­ duced myself I had the feeling that s he was not too sure about bei ng there. I asked her an opening question, ' What do you feel is your main problem ? ' , and then she began to talk. I did not h ave to ask many questions, she only stopped when she wanted to ask a question, and sometimes I j ust had to nod for her to continue telling her story. I have attempted to group Ruby's story i nto traditional categories. although the story unfolded as s he wanted to tell it. Ruby said she was 'inj ured' at work 14 months ago. She was a s hop assistant. 'Something definitely went in my low back ' . she said, ' when I was l ifting bundles of clothes onto shelves, nothing much differ­ ent from what I do normally, but perhaps the bund les were larger.' Prior to this there were just the ' usual aches and pains everyone gets, but I was fit and could

do anything'. Ruby admitted that work was 'a bit stressy' at the time because she worked in a large department store in which there had been some downsizing, a nd a few of her colleagues around her age had lost their j obs. She was working three half days a week and said that she was j ust managi ng, with not much time for anything else. Her goal was to return to her original three fu l l days of work per week. I asked Ruby to show me where she felt her prob­ lems were (Fig. 3 .1). She described a wide area of dis­ comfort in her lumbar spine and she ran her hand down her right leg in what looked like a combination of the L4 and L5 derma tomes (,I have done this so many time I think I have rubbed it 01T' , she stated ) . There. was a small area j ust rig ht of her lumbosacral segment that she said was particul arly tender and which she encouraged me to touc h. In addition her whole right foot 'didn't feel right', although there was no paraesthesia or a naesthesia. She had had some diffuse mid-thoracic pain for at least 6 months. 'My shoulder blades make cracking noises too', she added. In addition. Ruby complained of left lateral elbow pain present for 2 months, which she said had been 'dismissed as tennis elbow'. She commented, 'You are the first person to seem interested in my elbow. Most people don' t want to know, yet sometimes I think that the elbow can be as bad as the low back.' There were also some headaches and neck pain, but she felt that her lower back was the 'core problem'.


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--l---- headache �f---- Occasional neck pain

_Sc----i----f'=- "Cracking" "OMen upset"

"Tennis elbow"

.." � down leg if back is bad"

not right"

(a) Fig. 3.1


Body chart il l us tratin g the patient's symp toms.



What were your thoughts at this early stage!

• Clinician's answer My first thought was that Ruby had a pain state from minimal trauma and that there had been plenty of time for the inj ury to heal. Immediately my thoughts were directed at the possible processes that could be contribu ting to ongoing sensitivity. My i nitial thoughts are summarized in the reason i ng categories below.

Pathobiological mechanisms

Pathobiological mechanisms are likely to involve mul­ tiple processes. Although tissues have had time to heal, they are likely to be unhealthy and there may be significan t physical impairment. To explain her pain state, there are hints of peripheraJ neurogenic (e.g. area of leg pain) and central mechanisms (e.g. spread and

persistence of symptoms) . There is surely nociceptive (tissue-based) pai n , perhaps from combinations of deconditioning, acidosis, neurogenic inflammation, and persistent physical dysfunction. Upregulated nervous systems are likely to involve perturbed out­ put and homeostatic systems, such as the endocrine, autonomic and immune systems. Sources

there is impairment with peripheral neurogenic mechanisms, then a reasoned source is the L4 or L5 nerve root. If there is nociceptive impairment. then any of the mobile tissues may potentially be unhealthy and could perhaps be iden tified on physical examina­ tion. The anatomical sources of the central seflsitivity are impossible to identify, but descending endogenous pain control pathways, the dorsal horn and multiple brain areas, including sensory, motor, attention, mem­ ory and limbic systems, are likely to be involved.


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On the 'good' side is her disposition, as indicated by her comment 'its been there only 1 3 months' . Perhaps some obstacles to recovery are work difficulties and the widespread and worsening nature of her symp­ toms. r was encouraged at this stage.

Also. you state that she did not have any paraesthesia/anaesthesia. suggesting that you screened for this particular symptom. Could you highlight what sorts of screening questions you would use when the patient does not spontaneously volunteer the information?

Clinician's answer Management

Management strategies are likely to involve education regarding the nature of the inj ury, reasons for pain maintenance and unnecessary fears related to move­ ment. It may involve pacing activities in relation to sensitivity and devising activities that present learnt painfu l movements to the brain in non-painful ways. It will probably involve active and passive treatment of relevant physical impairments. S he will also need to get fitter.

Contributing factors

There are already hints of work-related stress. This lady has quite a diffuse array of symptoms. Can you comment on why you would want to know about all her complaints rather than just her main problem?

• Clinician's answer The biological processes behi nd all the complaints are l i kely to be the same, but all complaints are needed for a working diagnosis. For example, knowledge of the elbow pain could support a hypothesis of central sen­ sitization or a hypothesis of a generalized inl1amma­ tory disorder, or perhaps a local tissue-based pain state from inappropriate use of the part. The big picture is necessary for therapy. For example, it may be the elbow pain that prevents particular activities which may help the low back. Ruby's main problem(s) may weU vary during therapy. This appears to be a clinical feature of central sensitization. If explanation is hypothesized as a key manage­ ment tool, she will want all symptoms and features explained. It is important that Ruby knows that the elbow pain, the headaches and the cracking in the thorax are not new problems, but that they are likely to be an expression of one process.

There are many different questions that may need to be asked if the patient is reticent to volunteer infor­ mation. For example, with respect to other types of symptoms, it may be necessary to ask about pins and needles or whether there are a ny areas that are numb. Clinicians will need to ensure that the patient's comprehension of ' numb' is the same as theirs. This question is related to the sensory aspects of periphera l neurogenic/central contributions. Asking whether there are areas that 'don't feel the same as before the injury' or which 'don' t feel the same as the other side' can a lso be revealing. Other screening questions. seeking hints of autonomic and motor involvement, include changes in sweating, skin health and feelings of weakness.

• Clinical reasoning commentary The breadth and openness of the clinician's ' work­ ing diagnosis' is evident. As suggested in Chapter 1, a manual therapy diagnosis should be one that captures the clinician's understanding of the per­ son (Le. narrative reasoning) and the person's problem(s). This should include, as provided here, the clinician's j udgment regarding each of the hypothesis categories. It is not sufficient simply to identify structures involved, as this alone does not provide sufficient information to understand the problem and its effect on the patient. or to j ustify the course of management chosen. The manual therapy diagnosis must include a hierarchy of con­ siderations. including the activity and participa­ tion capabilities/restrictions, the pathobiological mechanisms, patient perceptions of their experi­ ence (i.e. psychosocial issues ) , specific impairments identified and their associated hypothesized sources, and contributing factors. The clinician's narrative and collaborative rea­ soning is also evident in this patient-centred inter­ view where he encourages the patient: to tell 'her story' in the way 'she wanted to tell it ' . This aspect

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beliefs, desires, motivations, emotions). the basis of

understand the patient as a person. including their

their perspective and how the problem i s affecting

perspective of the problem ( e.g. understanding.

their life.

of clinicians'

reasoning rcquircs


Symptom pattern

no sport. although she had tried tennis with painful

Ruby felt that there was always some low back pain. although it varied. The leg pain came o n when the back pain increased, or i f she did a lot of bending. Her few hours at work usua lly brought i t on. This involved some light lifting and general sales. The pains were genera l ly activity related. gardening for instance, but not necessarily. She mentioned that she 'could be watching television and the back and leg might hurt' . Further questioning revealed that sitting was perhaps an aggravating factor and 'staying sti ll could also bring it on' . If she was sitting or doing paperwork while standing at work, she would get uncomfortable and the leg pain would manifest. There were no par­ ticular movements that aggravated her symptoms and she said that her spine felt a ' bi t stiff ' . There were no autonomic or vascular type symptoms. ' [ j ust don't understand it and no-one else seems to either', she comp lained . The only things that would ease the pain were forgetting about it, time. or sometimes a few gin and tonics would 'take the edge off it or make me forget it'. Listening to music,

'especially Barry Manilow ' ,

would also help. but 'none o f that heavy rock stuff that my son listens to though'. She was smiling. [ asked her

results (prior to the accident she played vetera n's tournament tenni s , golf occasionally and enj oyed working for hours in the garden). Ruby had no specific activity goals but im mediately said that she would l i ke to spend more time in the garden as ' i t ' s crying out for attention ' . S h e s a i d spontaneously, 'I feel a bit caged in; I don't know wh ich direction to take. Sometimes

I want to fight the pain, but [ know

from experience that it won ' t do me any good. My husband avoids the garden and my son is too busy study ing.' When pains came on she usually stopped, although she said on some days, '[ j ust try and fo rget it and march straight thoug h ' . She wanted to return to 'work, not fu ll-time but about 30 hours per week, j u st the same as before.

I asked her whether she had developed any new movement habits after the inju ry. She thought for a moment and said, 'that's interesting ' . She explained that she now bent to the right to pick things up a nd she would squat rather than bend to reach the Ooor.

Thoughts, beliefs and feelings about the problem

about her family. Her husband of many years was


supportive and believed she should keep active, and her

was, there was silence for a few long seconds. 'Not

I asked Ruby what her concept of the problem

son was at un iversity and was happy. Her spouse was

sure ' , she said , 'but there is something wrong or out in

healthy, although his father had bad back pain, and he

my back, I know that, maybe a nerve or a disc or some­

had always believed in the value of exerc ise.

thing. I don't know why it seems to be spreading and

She slept well. She fu rther commented that 'every­

I am getting these new problems. I was worried it was

one asks me that and they seem surprised when I

a horrible arthritis l i ke my auntie had, so I was pleased

reply that sleep isn ' t a problem and once

I am in bed

[ usually sleep very well ' .

about the blood test (negative, see below). Someone mentioned fibromyalgia once, but not again. The physiotherapist says I have stiff joints and some neural tension. No,

Activity level s and goals

I don ' t really know what has happened to

me and [ cannot really understand why it does not go

Ruby ' s activity levels had altered considerably com­

away. It would be easier i f [ had a broken bone.

pared vvith pre-injury levels. She adored gardening

that heals and you can show the plaster cast to people.'

I know

but was frightened about damaging her back a ny

Ruby said she had hope that it could be fixed and

further. She had been warned to stop gardening after

she thought it would need some exerc ises and per­

the injury and now she 'just potters arou nd' for about

haps something 'put back in place ' . She wasn ' t going

hal f an hour. Wa lking was restricted to a few times

to give up and thought that there may be surgery that

around the block or about 30 minutes. She played

could fix it. The fact that it had been going o n for over

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a year was a big worry, and she added, 'J know the story on back problems i sn't too good' . Spontaneously she said, 'J really want to know what is happening in there'. I asked her what it was mce when she was angry or stressed and she immediately, almost resigned ly,

replied that i t was worse, especially if there was leg pain. J told her that that "vas the case for most pains. She said that she didn' t like going out now, and added 'My husband must be getting sick of it-J am not the happy bouncy person I once was' .

� R EASONING DISCUSSION AND CLINICAL R EASONING I J COMMENTARY Have any patte r ns (for example, related to pain mechanisms, contr i buting factors or prognosis) emerged for you from this

appropriate amount of movement in relation to her sensitivity.


additional information regarding the sym ptom pattern?

Could you comme nt on your im pressions/ hypotheses regarding Ruby's cogni tive/affective status (i.e. her perceptions of her experience),

• Clinician's answer

specifically w i th respect to any ' yellow flags' and

While a mechanical pattern has emerged it is not a clear pattern with a closely linked stimulus/response feature. It suggests combinations of primary hyper­ algesia (tissue based) and secondary hypera l gesia (central nervous system based ) . The fact that sitting and stand ing at work evoked pain suggests that con­ tributing factors such as work-related ergonomic fea­ tures and job stress may need addressing. Anecdotally. patients with hypothesized central sensitivity can sometimes sleep remarkably well.

What is your i n te r pretation of her 'easing factors' (forgetting about the pain , time,

posi tive/negative factors i n her prognosis for con tinued pai n , disability and l i kelihood of returni n g to wor k ?

• Clinician's answer The key yellow flags here are: a poor explanatory model that has included mul­ tiple explanations and the concept of ongoing tissue damage • the fact that pain is controlling her • her fear of activity-related damage to a structure • withdrawal from social interaction.

However it was not all bad. For example, Ruby still had hope, was seeking some self-help via explanation, had a supportive family and appeared likely to accept an active approach to rehabilitation.

alcohol and music) ?

• Clinician's answer These are frequent characteristics of central sensi­ tization. A small amount of alcohol may be a relaxant through central enhancement of the serotonergic system. The key thing i s that these features can be used as part of explaining about what appears to be central sensitivity. It may help to demonstrate to her that focussing on the pain may make it worse, how distractive techniques could be useful. and how she does have some control over the problem. To help to explain increased sensitivity, one could use the example of the more mellow Barry Manilow music being more acceptable than the heavy rock music. This observation could be related to get her to do an

Clinical reasoning commentary

The concept of hypothesis categories has been put forward in this book as a means by which thera­ pists can organize their knowledge and focus on clinical thinking. However, reasoning regarding the various categories of hypotheses docs not occur in any set sequence. Reither, clinica l reason­ ing is a dynamic process and j udgments regarding the different hypotheSis categories are interlinked. For example, here the clinician describes how the patient 's . report of 'easing factors' was not only

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supportive of the pal.hobiologkal mechanism o f central sensitivity. b u l also h ow L h i s same informa­ tion Illay also be used i n the management strategy of ex plana lion/ educal ion. The key aspect of c l inical reasoning evident in t he clinician's answer regarding Ruby's cognitivc/alfectivc slates is h is attention to both sllpporting und negat­ ing clues/evidence. While clinical reasoning has a scient i llc basis. it is not a hard science. Many patient

iden tify precautions

.�I)�(r�!!ltI �ags .

A radiograph taken 3 weeks arter the injury showed some degeneration of the lower lumbar spine, most marked at t h e L4-LS and LS-Sl levels, and a little worse on the right side. There was minimal encroach­ ment of Lbe intervertebral foramina at these levels. A more recent radiograph was similar. Ruby had been told that there was 'degeneration in the l umbar spine ' . A complete blood test revealed no abnormalities. S h e had been told t h at they were checking for arthritis a n d it had been explained t h a t t h i s was normal . A recent computed tomography (CT) scan was also reported as showing 'degeneration in the lower lumbar spi ne; no nerve compression ' . With these resu l ts plus my

presentations are multifactorial and filled with con­ flicting evidence. This req uires care to avoid prema­ t ure tlnal judgments and bias, where one or two key features are attended to and cont1icting evidence or competing hypotheses are neglected. This is demon­ strated i n the clinician's predict ive reasoning with respect to psychosocial risk factors for chronicity. or yellow flags. where he has idenlitled both supporting anu negating evidence.

subjective interview. I excluded serious pathology and I again reassured Ruby that 'it sounds promising ' . Ruby had tried a 'cocktail o f drugs' over the past year but was currently not taking any med ication. S he stated that she ' would rather h ave the pain, than enjoy the little benefit they give, and having to worry about what drugs do to my kidneys' . Bladder and bowel function she said ' were OK' . although there was sometimes pain with her bowel movements. Straining could evoke back and leg pain. S he felt that her stomach was much more sensitive than before the inj ury, when she could eat anything. Other than the pain, Ruby felt in reasonable health , a lthough she admitted to being unfit. She was a non-smoker and there was no impend ing legal action, 'I have practically given up sex ' , she added .



• Clinician's answer

What were your thoughts regarding this information?

Clinician's answer

I thought that there was no need to refer her back for further medical assessment and I felt I coul d reassure her that there was no serious u nderlying disease process. I also thou ght it might be worthwhile getting her doctor to reinforce this. I n addition. I fel t more positive considering her attitude regard ing drugs and the lack of impending legal action.


Did you think the difficulties with her bowels and the increased sensitivity of her stomach warranted any concern and follow-up investigation?

No. My reasoning was that bowel-related pain was mechanical and perhaps rel ated to ongoing nerve root sensitivity as it increased leg pain . At this stage, increased stomach sensitivity could be seen as part of a central sensitivity.

• Clinical

reasoning commentary

Screening questions serve the purpose of identily­ ing whether other types of symptoms. aggravating or easing factors and. as used here. specine red flags (i.e. symptoms and signs requiring emer­ gency referral to a spinal surgeon and signs and

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symptoms suggesting possible serious pathology) are present that the patient may not have sponta­ neously volunteered. Yellow flags (i.e. psychosocial risk factors of chronicity ) . including blue nags (patient's perception of work) and black flags

(actual work characteristics). and symptoms and signs suggestive of a non-musculoskeletal disorder masquerading as musculoskeletal dysfunction should also be routinely screened.


Active movements

looked at Ruby 's general posture and noted a kyphotic thorax and a slight forward head posture. In general. her back looked strong with well-developed musculature. I thought how chronic pain was such that it could be masked and a hidden phenomenon in society. I\m I looking i n the right place ?' I thought. She coul.d squat, and there were no great abnormal­ ities detected when r observed her waJl<ing. Balance on either leg was not good, especially the right leg. which she could only balance on for a couple of seconds. Ruby's active lumbar movements seemed reason­ able. Lumbar extension looked stiff, particularly in the low lu mbar region. and I noted that during exten­ sion she sh ifted to the left. away from the painful lower limb. The movement was restricted but no pain was produced. Lateral l1ex ion to the right seemed a bit more restricted than to the left. particu larly in the lower regions. On lumbar flexion, there was a pulling sensation and some diffuse pain across her lumbar spine and buttocks, although she could nearly touch the 11 0or. These symptoms increased when I carefully added cervical flexion. I looked at thoracic rotation only. There was some stiffness and a little mechanical hyperalgesia in the thorax on rotation to the left. In addition, there was also a cramping feeling in the thorax. Ruby could lift her arms above her head easily and without discom­ fort. 'That crackling noise should go when you are moving better' . I ex plained. During cerv ical spine retraction, the thoracic pains were provoked. I

Passive movements I performed a quick palpation examination. There was no excessive warmth in tl1e tissues and I palpated the thorax and lumbar spines both cen trally and u ni­ laterally. Ruby was byperalgesic all along her thorax, especially a t the mid-thorax where it felt particularly

stiff to posteroan terior passive accessory in terverte­ bral movements. The l umbar spine was also hyper­ algesic, particularly the lower lu mbar region and espec ially on the right side. although I could not detect any localized stiffness. There was also multiple area tenderness when I palpated over the sacrum. Neurodynamic testing revealed: Straight leg raise (SLR) of the left leg was 80 degrees with a pulling feeling behind the knee. • Right SLR was abou t 6 0 degrees with some pulling sensation behind the knee and a 'dragging feeling' in the l umbar spine. • Passive neck flexion in supine lying produced a very slight pulling feeling in the lu mbar spine and a mid-thoracic pain at end or range. • The slump test was performed actively with some guidance. On in itial slump 'nothing' was felt. The addition of neck l1ex ion 'pulled ' in the thorax. and left knee extension at minus 1 0 degrees 'pulled ' in the mid-hamstring area. Right knee extension was about minus 20 degrees and evoked symptoms in the back and thorax. There was also a 'vague numbish' feeling in the right foot. All of these symptoms were eased when the cervical spine was extended. even with j ust upper cervical extension . •

Neurological examination

While standing. heel walking revealed some right­ sided anld e dorsillexor weakness, and heel raising also showed some slight right-sided weakness. For both these quick tests, weakness was only evident after five or six repetitions. 'Is it safe to do this?' she asked. 'No problems. you are doing wel l ' , I replied . Her quadriceps rel1exes were equal. although somewhat hyper-rellexic. The ankle jerks appeared equal and normal. There was a slight decrease in strength in all right-Sided muscle groups below L2 . I thought that the L4 muscle test (ankle dorSiflexion)

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stood out as the weakest. The tendon oC the contracted right tibialis anterior muscle was softer to palpation than on the left side. There was hypersensitivity in her posterior right leg to a cursory light touch exam­ ination, although this could not be localized to a dermatome. Mild, bilaterally equal ankle clonus was evident. I told her that her ' nerves were firing wel l ' . Pinprick was n o t performed . Ruby said that she was a little sore in the back after the examination. I reassured her that this was natural. Initial assessment

The above subjective and physical examination had taken me about 45 minutes. [ told Ruby that I would need to continue the examination and get some more details next time. As she left, I told her that I wanted to achieve four things for her within the next few visits: 1.

Explain what I thought was wrong as far as the most current scientilk understanding of spinal pain would allow ( th is would include why the problem was stUI persisting):

Clarify how long it would take to improve and what improvements were possible: 3 , Present all the options of what she could do for it. 4. Advise her what physiotherapy could do for the problem. I said that I was sure I could help her and s how her how to manage her problem. 2.

She looked at me somewhat quizzically, said ' thanks' and left. I wasn't sure whether she was going to come back. During the examination, I made notes on what I thought I should specifically attempt to explain to her. These i ncluded: • • • • • • • •

why the problem had not gone the spread of pain what the tennis elbow meant the cracking noise under the scapula why pain came on for no reason why there had been various explanations for the problem why moods affected the pains the radiograph findings.

REASONING DI SCU S SION AND CLINICAL REA SONING COMMENTARY Please comment on your thoughts regarding


Many patients expect to receive some 'hands-on'

whether your findings on the phYSical

treatment at their first appointment. Could

examination fitted with your thoughts following

you briefly discuss your views on this and the

the subjective examination, with respect to

risk that the patient might not return, as you

pain mechanisms and sources associated with

commented above might be the case with

her symptoms and impairments.

this lady.

• Clinician's answer

• Clinician's answer

Yes they IItted. Ruby may have had better general movements than [ thought she would, but this i s understandable with a hypothesis of central sensitiv­ ity. I believe that because I spent a significant amount of time with the subjective evaluation and let her tell her whole story a clinical environment was created which allowed her to move reasonably well. There is clinical evidence of peripheral tissue involve­ ment (e.g. neurological findings, area of symptoms) and a pattern that. on the basis of modern neurobiology in particular, could be argued as central sensitivity.

[ believe that it is a myth that this kind of patient desires hands-on treatment at their first visit. Often many patients have had failed hands-on treatment. In this particular case, my reasoned j udgment was that her desire for information and support was much stronger than for an instant ' fIX it'. If a subjec­ tive enquiry reveals that a patient really wants mobilization, traction or ultrasound, then it may be worth giving it to them, so long as the therapist and patient do not fal l into the trap of bel ieving that this is the l ilcely sale and necessary treatment.

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The danger is that the delivery of such techniques, with possible short-term beneficial results from treat­ ment, may reinforce the notion that. tissue damage is the only cause. The patient has to see the place of physical findings in the big picture. as much as clinicians must. Most patients want a good physical eval uation. There is plenty of usel'ul therapeutic touch in the physical exami nation. Perhaps we should rea l i se that the physical examination i s in fact t.reatment. and that the patient is consciously and subconsciously learning from your physical examination. In retrospect. in this particular patient, my fears 0(" her not returning reflected my own insecurities. not hers.

• Appointment 2 Ruby arrived early for the second appointment. She said that she felt quite tired after the previous exam­ ination. I quickly went over things t.hat. I had forgot­ ten to ask in the first examination or which need ed confirmation. S he h ad received previous treatments. The thorax and l umbar spine b a d been manipulated many times by various professionals. This would usually give rel ief. though not always. Hydrotherapy was tried but did not help. She had tried various exercises but found ' when I concentrate on the back, it. sometimes gets worse afterwards'. I rechecked the active movements ( no cha nge i n pattern observed at first appointmen t) , performed a Babinski examination (negative) and performed a closer palpation or her l u mbar spine. The left L4-L5 area was the most tender, although the same general­ ized tenderness was evident. Both SLRs were similar to Day 1. perhaps a little better. With the right ankle dorsil1exed and inverted, and then the leg raised, there was significantly more hamstring and back pain than on the other side. r checked the slump test in long-sitting. Pain was evoked in the m id-thora x in this position and could be eased by cervical extension a nd by both left and right knee flexion. I performed a left upper l imb neurodynamic test (Butler. 2000) for the radial nerve. There was a l ittle

Clinical reasoning commentary

As the clinician pOi l l ts out. hands-oll treat lllcnt is not essential at the IIrst appointment. Munagemcilt is. however. He right·ly argues that a thorough examin­ ation should be seen as part or management and t hat explanat ion/education is an i m port an t . sometimes lhe most important. aspec t of our management. For some patients with complex presentat.ions such as this lady's, allOWing time for a more thorough exam­ ination and explanation of lilldings is ll10re appropri­ ate than shortening the examination for t he sake of trying to lit in a spccilic hands-on treatment . But such decisions are not always clear-cut and t hey must be made collaborativcly with the patient.

more sensitivity over the lateral el bow than on the other side, but no apparent tightness or sliffness. I said that I thought that modern science could provide a reasonable explanation for her problem and that I should go over that IIrs t I a lso said t h a t there were a few things I could do and that there were many t hings she could do to help. The intercha nge below was my attempt to explain the problem: .

Clinicial1 I think after listening to your story and examining you. that there has to be some un heal thy. unfit tissues in your lower and middle back. Certainly there are many tender joi nts and sensitive nerves, and a lthough I haven' t tested muscles yet-I will la ter-they are sure to have lost some of the norma l heal th and vitality they had before your problem began. You probably did strain some joints and muscles in your back a few years ago, as wel l as probably having some nerve irrita tion . which caused the leg pain. and these tis­ sues are still a bit sensitive. However. one thing is for sure, over the last year the inj ured tissues h ave had every cha nce to heal and these present pains a ren't real ly serving the original purpose of the pain, which was a warn ing and a call to action. R uby OK, I would l ike to get things a bit health ier. but how? It j ust h urts so much. And why doesn ' t it get better? There has t o b e something wrong i n there. I am n o t p u tting it on . Clinician I know you aren't and we have to answer those important q uestions. I think [ can offer you a

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good scientillcally based explanation of why your back is still so sensitive. Ruby I'm all ears. Clinician Your once-injured joints, muscles and nerves have had plenty of time to heal. As you know, even a broken bone will heal up nicely in a couple of months. A lso, by your decreased activity you have protected yourself. maybe overprotected , from re-injury. But for various reasons, which we' ll explore. the tissues are still unhealthy and sensi­ tive. However, they can be made a bit healthier and made to move better, given more blood , and the oil in the jOints can be made healthier and slipperier. They are sensitive but they are crying out for movement. Ruby OK. but why is it still hurting and shouldn't my attempts to move make me feel better? I always used to feel great after exercise. It's not for the want of trying you know. A couple of times 1 have said 'sturr it' and gone and exercised and wal ked lots, but I really pay for it afterwards, sometimes not even sleeping for a couple of nights. Clinician Well , it's partly those sensitive unhea lthy tissues and getting the right balance for the amount of exercise, but it's probably also because there has been a few sensitivity cbanges right throughout your nervous system. Ruby What on earth do you mean by that? Clinician Well , there has been a lot of resea rch into pain mechanisms over the last few years. We now know that when there has been a tissue injury, particularly a painful one such as a joint injury or particularly a nerve compression. and if there has been a bit of stress at the time, that the whole ner­ vous system not only becomes more sensitive, but it can also stay sensitive. Ruby Are you inferring that this is a ll in my head David? Clinician Well no, but yes in a way, in a very real way in your nervous system. I have no doubt about the reality of your pains. This is not easy to explain so bear with me. There are some problems in the tissues but we now know that repeated impu lses into the nervous system will make it more sensi­ tive. more ready for action. It's a natu ral thing. It happens in everyone, but for some reason, in some people, these nerves stay sensitive. If this hcippens, it means that inputs from other parts of the body like the elbow or the thorax can also report pain . Sometimes old pains that you thought

had gone cou ld come back. It is rather like there is an amplifier or a magnifier in your body which makes everything seem worse than it is. Perhaps you could have handled your son's rock music in the past. but now because of your sensitivity being a bit turned up, it is more difficult. Ruby Sounds possible. Maybe that music does bug me more these days. And I did have bad elbow pains about 5 years ago. I am not sure about some scientists though. I j ust want you to know that I am not making this up. Clinician r don't think you are making it up and if some colleagues of mine have suggested that. then that is unfortunate and all I can do is apologise. But a ll pains are real and I am j ust being a mouth­ piece for a lot of recent scientilk work. If you want to read about this, r can give you some short art­ icles which I have written. Ruby Maybe later, perhaps my hus band would be interested. I want to hear more from you . Clin ician Let m e try and express this on a cliagram (Fig. 3 .2 ) . From my examination, I believe that there are a number of tissues that are sensitive and a bit unhealthy. There are also changes related to sensitivity in the spinal cord. r know that sounds awful but, as r said. it happens to everyone. We are l ucky to have this wonderful nervous system that can keep changing its sensitivity depending on how much we need it. r am sure you have heard stories of people who really want to complete a game of sport and during the game they sustain some nasty injury but they can complete the game. We all have the ability to turn the pain system up and down as we need it, and of course some of the changes are automatic. However, sometimes the pain system stays turned up and there is a sort of a magnifier in your system. For example, when I touched your back gently, it hurt. Now there is nothing wrong with your skin otherwise we would see it, but the touch is going into the central ner­ vous system where it is turned i nto pain. Don ' t worry, this is very common. We all get it t o various degrees and we often see patients where minor inputs such as a collar rubbing on the neck or a little draft seems to cause pain. Ruby (After some time looking at the drawing.) So you are saying that the pains I am having are not really the pains I have got. Clin ician (1 was a bit stunned by this response.) Well. yes and no; perhaps more yes. r think that

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S;o"'J",,,, .s''f�''''J'

1'1""4 �..., Nt;


Co e.Jl �,--

Fig. 3 . 2

Graphic description o f the patient's pain state.


/ there are some pains/coming from the j oints, muscles and nerves o(the b ack, but you are right and up to date sCientifically if you are thinking that the pains you are experiencing may not be a true rellection of the state of tissue health and healing in the spine. We have to get your whole system less sensitive as wel l as making those tissues more healthy. Are you OK with all this? R u by Yes I think so, but I wan t to discuss this with my h usband. Clinician OK, sure. You can bring him in next visit, if you want. I am going to give you some articles to read and you can give them to him as well. R u by It's comforting to know that I am not alone here. I am looking forward to starting something. What sort of things will I be doing? Clinician You have started already: Sometimes when you know a bit about what is going on it takes a bit of sensitivity out of your system already. R u by Yes that's right I am sure, but shouldn ' t I b e given some exercises? /'

Clinician Let's call it activity rather than exercise. I had to leave the room for 5 minutes. (When I came back, Ruby looked a little concerned.) R u by I don ' t really understand it. I can follow your story about impul ses making the nervous system sensitive. It sounds sensible, but why me? Why hasn't everyone got chronic pain? Clinician Well. there are more people with chronic pain than we ever thought. Approximately one quarter of all Australians have some pain that doesn't go away. In your case, I don't really know for sure, but we can make some educated guesses. First of all, the type of inj ury is likely to be import­ ant. From the sound of it, we .c an guess that the initial injury may have involved irritation of a nerve. That test when I asked you to slump and lift your legs suggests that there is a bit of irritation or tightness around some nerves, plus there is some minimal wealmess and funny feel ings in the foot . That's from nerve irritation in the back. I f you remember, the test was more sensitive on the right side. There are parts of the nerve close to the spinal cord and near the disc (desk model shown) that keep buzzing for a time after injury. Also, when there is a bit of adrenaline around, which there always is when there is an inj ury and if you get a bit stressed or upset, it will also make damaged nerves more sensitive. A nerve can be sensitive for q uite a while but they nearly always get better, especially if you keep reasonably active and under­ stand what is going on. Second ly, the sensitivity within your nervous system can be increased for a number of reasons. You could th ink of them as things that are stressing you, some of which you may not be aware of. Novv I hardly know you, but j ust from our two meetings I can see a few reasons for increased sensitivity. For example, with failed treatments and lack of explanation or direction, it is no wonder that you remain sensitive. If you feel as though you have to prove there is something wrong, it naturally only uplifts your sensitivity and this is often the case where there are problems at work. It's a natural survival thing. Walk through the d ark and you become more sensitive to the surrounds. This must be related to the fear of not knowing. Your brain in a small way is fearing for your survival so it lifts the sensitivity and makes more stress chemicals like adrenaline and cortisol. We haven ' t discussed it but it is only natural that

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you would have some concern for the future. I know you love gardening and perhaps even looking at a garden that needs care is stressful. Work issues are probably stressful. There may be other things in your lile that you can think of which may make you a bit sensitive. They may be worth thinking about. Ruby Maybe. At the time of the accident 1 remem­ ber being very angry. It was very painful but 1 don't think they believed me you know. There had been a few women off work and 1 thinl< they thought we were having a go at the system. It was the same when 1 had elbow problems 5 years ago. And by the way, have you had a look a t the X-rays 1 brought in? Clinician Oh yes. let's look together. There are some changes but they are rea l ly j ust the kisses of time. We all get them and there is nothing to worry about in the bones. Your bones look heal thy. An X-ray can't tell much about damaged tissues; sometimes the CT scans can but your CT scan was great. These are typica I for someone your age, with or without pain. Ruby Well. it's a worry with a l l that wear and tear, but I follow you . Clinician 1 said during the first visit that I would try and answer [our things: what is wrong, how long i t will take to get better. w h a t you c a n d o and what 1 or anyone else can do. Hopefu lly. 1 have begun to answer the first. How long it will take to get better is hard to answer, b u t I am sure that you will be able to function much better once you u nderstand the nature of the pain, that you can edge into it. explore it. even play with it and know i t won't harm you . It may never go completely and there will probably be a few l1are-ups, but this does not mean your management is failing. Thirdly, what can you do? From my examination, I believe that you have every reason to remain positive and being positive will help. S imply, posi­ tive people make happy healing hormones. We know your nerves are working; we know there is no serious pathology and you are moving quite well. There are a number of things you can do, but it's really all about movement. Edging into pain with less fear is one way. but 1 think you and 1 could also come up with a paced exercise prog ramme; that is, a series of activities that you know can hurt but which are performed short of pain. It is teaching your brain that activities that normally hurt don't

have to hurt. When we set a n exercise programme. we can make some goals, for example increasing time and activity i n the garden. There may always be some pain and you may need to be more active for a while before it settles. For the moment though. try and minimize activities that cause the shooting pain down the leg. I will also d iscuss other management such as using heat and cold and relaxation. Fourthly, what can 1 do? The big picture aims are to get you a bit fitter, a nd happier to move with greater u nderstand ing of your problem. There are some specinc exercises I will add. but they can wait until next visit. This will include some general slump exercises to improve l1exibility and I think it is worthwhile getting some of the local muscle groups around your low back and the front of you r neck more active. I think t h a t in this k i n d of long­ standing problem, there is unlikely to be a single magic click or d rug or surgery that can fix it. 1 will also expl ain what 1 am doing to the nurse a t your work a n d 1 w i l l ring you r doctor a n d send a shor t report. Appointment 3 Ruby arrived very early for the appointment. She seemed nervous. '1 don ' t thinl< 1 need to come any­ more', she said. 'I have been thinking about it all night. For years 1 h ave been going to doctors and spe­ cia lists and therapists and I am sick of it. I rea lly only ever wanted two things. 1 wanted a good examination and 1 wanted to know that I cou ld go back and do more garden ing and more activity without harming myself. I feel I can do that now. 1 a m j ust going to slowly work into it a bit more each day. Minor aches and pains, I won't worry about but I will stop at around half an hour and then I will try and i ncrease that the next week. maybe do some digging and plant­ ing. That will nt nicely as the days are getting longer now, but I am going to gradually work into more activity, maybe even have a few hits of tennis with my children. I will ring you if 1 need you and 1 would be very grateful if you could explain this to the industrial nurse and the doctor. I will increase my time at work. Thank you very much.' 1 was very surprised. 1 thought 1 had a lot more to offer her, but 1 felt happy with her responses. 1 h a d intended t o manage her for approximately 6 weeks,

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with one visit per week. I had written down my plan for management and it included the following. • Reassess physical signs i ncluding her neurological

signs. • Reassess her hoperuUy changing beliefs and thoughts

about her back, her pain and activity. • I was going to talk more about movement and the

brain, how the brain is hungry for new inputs, how i t changes with loss of normal inputs and how physical exercise is as much for the brain as it is for the body. I wanted to keep adding some inIormation each visit. • Check the need for slump mobilization and spinal exercises. Perhaps treat with some passive as we l l a s active slump mobilization. I may have mobilized or manipulated j Oint segments eventually, if I felt sure she understood where such a treatment fitted in to the big picture. • Try and c hange the maladaptive movement habits. This could begin with the new habit that she had developed to pick thinks up 0[[ the 1100r. Somehow, movements that have been learned to be pain[u l need to b e presented t o her brain i n a non-pain[ul way. This may mean paCing. brea king down movements a n d using different orders of move­ ment. For instance, there are various d ifferent ways o[ getting up [rom a chair.

• Introduce and mod ify a gradual paced programme

involving time in the garden. I wanted to establish some base activity levels and then increase these. I would also do this with walking. • Discuss other coping measures, including some strategies [or l1are-ups. Strategies could include use or heat , clistraction and relaxation exercises: maybe get a dog etc. • Invite her husband in during one visit (or more explanation. • Initially I thought I could manage her by myself, liaising with the doctor and industrial nurse. I[ there were no quick benefic ial responses I thought that a formal investigation of psychosocial aspects might be relevant, although there were no out­ standing contributing [actors fou nd in my initial interview. Perhaps I shou ld h ave rung Ruby back. but she had said that she would ring me and I respected that. Her doctor told me she was managing better. About 6 months later. her daughter came into the clinic with an inj ured knee. referred by her mother. 'How's Mum?' I asked. She replied, ' Yeah, not too bad. She's out in the garden a lot. plays a bit o[ tennis. seems happy at work, still grumbling about her back pain though.'



This patient's perceptions of her experience (i.e.

caused by a secondary hyperalgesia or allodynia).

her understand ing of her problem and beliefs

Specific physical treatment for a patient w ith

about what she could do) were obviously in

chronic pain is discouraged by some and has

themselve s part of the problem and partly

been suggested may even constitute overservicing

hold ing her back from getting on w ith the

while fur ther contributing to the patient's

activities she enjoyed. Clearly your management

reliance on a passive solution. Could you share

in the form of explanation seems to have

your views on how to determine the extent that

contr ibuted Significantly to her ability to do

any physical impairment, such as of neural

more w ithin her pain. I t is also evident from your

mob ility or muscle control in this particular

'plan for management' that in addition to fur ther

case, might still be contr ibuting to a patient's

explanation, you also intended to incor porate

pain and disability and the process you follow to

treatment aimed at addressing some of her

determine their significance ?

general and s pecific physical impairments (e .g. fitness, neural mobil ity) . With the increased under standing of chronic pain there is sometimes the implication that the physical Signs/impairments identified in an exam ination are not relevant (i.e. false-positive findings

• Cl inician's answer If I thought that physical signs were not relevant in chronic pain, then I would not have spent the time performing such a detailed physical evaluation .

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I n addition, I a m not aware of any 'authority' who would disregard the management of relevant phys­ ical impairment in acute or chronic pai n . The key is the word ·relevant' . A simple way to answer the ques­ tion of relevance of speciftc physical impairment is to ask. ' is this a physical sign that needs to be altered to make the patient function better?' In addition, some knowledge of the neurobiology of pain can help. Modern neurobiological science makes it clear that many of the physical signs that well-meaning manual therapists in the past have collected are not jus t indications of processes i n the tissue that are presumed to be tested. They are a represe ntation of tissue factors and nervous system factors. Nervous system factors include the representation and mean­ ing of that particu lar examination technique at that time and in that space. This does mean that fa lse­ positive findings must occ ur. With Ru by, my j udg­ ment would be t h at the slump responses were a combination or tissue factors and an upregu lated central nervous system. Hence u relevance j udg­ ment requires an understand ing of neurobio logy and pathobiology. This knowledge is often lacking in manual t hera py. Specitlc physical impairment does not have to be treated by specific physical techniques. Our physical techniques are j us t one tool. which in the case 01' this patient I may have employed. Specific physical impair­ ment may also improve with better understa nding. reduction of fear. touch, better general physical health. and return to activity.


At the star t of this case , you note that this patient was one of four from your career that 'stand out as s ignify ing changes in my understanding of clinical prese ntations and my professional direction'. Could you comment what was i t about this patient that made such an impression on you?

• Clinician's answer It was the third day when Ruby said she did not need to come back. It was a powerfu l moment as we j us t looked a t each for a period of time not saying any­ thing. I think we were experiencing similar feelings: she some form of awakening and a realisation of the meaning of pain, wh ile I was sti l l awestruck by the power of taking the messages of pain science to patients.

• Clinical reasoning commentary On completion of the patient initial examination. whether achieved i n the first appointment or over several. the manual therapist should have identi­ fied speciflc hypotheses in each of the hypothesis categories (see eh. 1 ) . Collectively, these hypothe­ ses represent the t herapist's 'diagnosis'. which includes his/her understa nding of the problem. the person. the elrects the problem are having o n the person's life. and appropriate management strategies. Huwever. except for very s traigh tfor­ ward patient problems where the clinical pattern and course or management arc not in any doubt ( i.e. no problem solving req uired) . the hypotheses reached through the examination must then be tested through the managementlreassessment process. As tbe clinician discusses here, even with a hypothesis of a dominant pathobiological cen­ tral pain mech a nism, physical impairments ( speCific or general) may still be relevant. In fact. speaking at an u npublished pain sem inar in Australia. Patrick WalJ discussed this very issue and sh a red the story of a patient whose central sensitivity and psychiatric symptoms were main­ tained by a specific physical impairment or his kid­ ney. The point here is that it can be very difficult to be cer tain in the more complex patient presenta­ tions what is necessarily relevant and whether identified physical impairments are the result or. or the trigger to. a concomitant central sensitiza tion. Hence. as discussed in Chapter 1 . the reason ing process must continue through the ongoing man­ agement. Often it is not until physical impairments have been addressed in the management. and the pat.tern of response to such management is revealed. that the therapist can reach a more secure decision. As manual thernpists. teaching is a central com­ ponent of Ollr management with most patients. While some o f our teaching is i nstrumcntal or pro­ cedural in the form of specific exercise instruction. much of our teaching centres around aSSisting patients to renecl 0 1 1 their own perspectives (e.g. beliefs and health attitudes ) ; through this self­ rel1ection and our explanations, our patients learn: that is they acquire new perspectives or u nder­ standings of their problems and their manage­ ment. Similarly. through rel1ection, clinicians can

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also learn and acquire new perspec ti ves ( trans­

thinking, bel iefs and knowledge limitations). an

I ) , Cri t i c al

attribute characteristic of experts in all professions

self-rellcction requires metacognition ( h igher order

and the means by which clin icians shift their

th inkin g and awareness of, for example. your own


formativc learning, as d iscusscd in Ch ,

Reference Bu tler. D.S.

( 2 000). The Sensitive Nervous System. Adelaide.

Austral i a : Noigroup Press .

• F u rther reading G i fford. L.S. (ed . ) Issues in Pain CNS Press.

( 1 9 9 8 ) . Topical 1. I'almouth. MA :

G i fford . L.S.(ed.) Issues in Pain

( 2 000) .Topical 2. Falmouth. MA:

CNS Press.

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Wa l l . P.O. and Melzack. H . ( 1 999) Textbook or Pain. 4th edn. Edinburgh: Churchill Livingstone.

C h ro n i c low bac k pai n ove r 1 3 years Dick Erhard and Brian Egloff


A 3 0-year-old Caucasian male (David) presented to the

magnetic reso nance imaging (MRI) sca n , he was

clinic with a chief complaint of bilateral anterior groin

d iag nosed by an orthopaedic surgeon as having a

pain, in addition to severe low back pain (LBP) and hip

herniated nucleus pulposus at L4-L 5 . He described a

area pain. He indicated on a pain d iagram (Fig. 4. 1 )

series of incidents of LBP in the years between being

that h e was experiencing sharp pain i n the lower por­

diagnosed and the present time, associated with only

tion of both buttocks and a deep ache on the anterior

minor or even no precipitating events. Each time chiro­

and posterior aspects of both thighs. He did not indi­

practic treatment, physical ther apy, prescribed exer­

cate on the pain diagram that he was experiencing

cise or pain medication brought him some relief.

groin pain. but during the interview he motioned with

David also described how treatment with methyl­

his hands in a manner that indicated he felt pain bilat­

prednisolone (oral steroids) brought him almost com­

eralJy in the anterior groin region. David related that

plete relief on one occasion . However, after the dose

the symptoms were so severe at tin1es that they caused

pack was completed the bu ttock pain returned. Most

him to limp when walking. However. on the visual ana­

recently, David had enrolled in a yoga class. His hope

logue scale ( VAS) he rated his pain in the last 24 hours

was that the stretching would help to relieve his

as 2 1 1 0 , both at its worst and at its best (where 0 is 'no

symptoms, b u t he felt that the stretches had actually

pain' and 1 0 is 'extremely intense' pai n) . He also

aggravated his b u ttock pain and they had no effect o n

pointed out that he felt stiff in the low back and right

the LBP. H e a l so indicated that prolonged sitting, s u c h

posterior superior iliac spine (PSIS) region in the morn­

as at h i s desk at work, increased his symptoms a n d

ing, but that this resolved as he went about his morning

t h a t movement somewhat alleviated t h e symptoms.

routine. F urthermore. he related a feel ing of his pelvis being 'rotated forward ' . David's hand gestures when describing this pelvic rotation were consistent with a

Questionnaire fi n d ings A medical intal<e q uestionnaire revealed that David

lateral shift of the lumbar spine. Upon questioning, David explained that his symp­

had not experienced any recent unexplained weight

toms began approx imately 1 3 years ago when he sat

loss, nor any bowel irregularities or abdo mina! symp­

down after a round of gol f. At that time he no ticed

toms. He indicated he had experienced night pain at

right bu ttock pain, and the symptoms had been

the onset of his symptoms, but when further ques­

episodic ever since. He reported that the current

tioned he related that this had not recurred in years.

episode was the worst, although at the time of the

He also indicated on the questi onnaire that he experi­

clinical evaluation his symptoms had decreased . Four

enced weakness in his legs during walking and epi­

years after the onset of symptoms and following a

sodes of his legs giving way (right more so than left) .

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Fig. 4 . 1

Areas o f pain indicated o n the pain diagram b y the patient.

When questioned further about this weakness, David added that the weakness was related to distance and that during this most recent episode he had found it necessary to rely on crutches for ambulation. At the time of his ori1ce visit, he was not using an assistive device to aid him in walking. He also indicated that there had been episodes of bladder urgency, when he

� J D

had to rush to the bathroom on his crutches and quickly void to prevent urinary incontinence. Upon subsequent inquiry, he revealed he had never lost control over his bladder and had not experienced any burning sensations during urination. David denied having any paraesthesia or nwnbness in his extrem­ ities or groin region.


What were your initial thoughts about the pattern of onset of the symptoms, particularly regarding their episodic nature?

Clinicians' answer

Instability is characterized by exacerbation from minimal perturbation . The fact that the patient had had numerous episodes of LBP over the years caused by insignificant or no precipitating events tended to suggest a diagnosis of instability. The onset

at an early age was a lso consistent with this syn­ drome's presentation, as was the temporary help he obtained from chiropractic care. The patient's use of a supportive device (crutches) with some relief provided further support for the instability hypothesis. Finally, the patient gestured with his hands what appeared to be a lateral shift compatible with lumbar instabili ty. Conversely, the patient did not indicate he was a 'self-manipulator' , which tended to negate the hypothesis of instability, as did his gender.

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We re you at all concerned about the episodes of

• Clinical reasoning com mentary

bladder urgenc y ? Did you consider investigating this problem furthe r?

• Clinicians'

The clinical diagnosis of 'instability' hHs Jccn bypo­ thesized as the cause of (or factor contributing to) the patient's symptoms. based on the recognition of typical cues associated with this dinical pattern, and probably considering the fact that this is a disor­ der with a relatively high prevalence. A second precautionary hypothesis related to potential mechanical causes o f bladder dysfunction is given less weighting, based on an absence of typically associated cues and probably considering the fact that cauda equina syndrome is a disorder that is rarely clinically encountered. Nevertheless. i t is important to note that neither hypothesis has been accepted or rejected at Ihis early stage. which would have constituted an error in the clinicians' reason­ ing, with additional testing of these hypotheses to be undertaken through further questioning and stan­ dard physical examination procedures.


Not really. as it was apparent these episodes were not persistent or worsening. Upon questioning the patient further. it was clear he was not describing a spastic bladder (no feelings of constant fu llness or episodes of voiding abnormal ly small volumes of urine) nor any episodes of urinary incontinence (no dribbling as would be expected with a flaccid bladder). In addition. these episodes were not constant and ongoing. certainly not the frequent urgency one would expect from a spastic bladder. He merely had a couple of instances when he had to rush to relieve a ful l bladder and thus no further investigation was warranted at this stage.

Analysis of the i mpact of pai n David filled out a Mod ified Oswestry Questionna ire (MOQ). a 1 0-category inventory of a patient's perception of the disability they have incurred as a result of their LBP (Fairbanks et ai., 1 9 8 0; Hudson­ Cook et al.. 1 9 8 9 ) . In each of' the 10 categories, the patient is asked to select the statement that best applies to them from six possible responses that vary sligh tly in their descriptions. For example, the state­ ments in the pain intensity category range from 'The pain comes and goes and is very mild' to 'The pain i s severe a n d does not vary much ' . In addition to ques­ tions relating to pain, the categories also include questions pertaining to functional tasks. such as sit­ ting. standing and walking. Each category is then graded from 0 to 5 depending on which statement the Table 4.1 Stage

patient selects. The category scores are totalled and multiplied by two to produce a score out of 1 00'X.. Thus, the higher the percentage the more disabled the patients perceive themselves to be as a result of their back pain. David 's score was calculated to be 46%, indicating that he viewed himself as being significantly disabled when performing daily tasks. An initial MOQ score of 40-60% is one of the criteria used to assign a patient a stage I classification (Table 4 . 1 ; Delitto et ai., 1 99 5 ) . I f the initial score is extremely high (greater than 60%) and the episode is more than a few weeks old. it raises the suspicion of an affective/cognitive component to the patient's complaint. An elevated score on this ques­ tionnaire may also indicate a serious non-mechanical disease process that is not amenable to physical therapy intervention (e.g. metastatic bone d isease).

The Modified Oswestry Questio nnaire classification system Score



Unable to sit for more than 30 minutes, stand for more than 1 5 m i nutes or walk for more than 400 metres without symptom aggravation



Has more tolerance for sitting, standing and walking than stage I but instrumental activities of daily livi ng. such as housecleaning or yard work. cannot be tolerated


< 20%

Reserved for individuals whose occupation places a high demand on their lumbar spine. e.g. manual labourer or elite athlete

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At the conclusion of the interview, what were

Considering the recalcitrant nature and unusual

your clinical impressions? Specifically, what

pattern of the patient's pain, did you think at all

hypotheses were you entertaining with respect

at this time about the pain mechanisms that may

to the source(s) of (and factors contributing to)

have been involved ?

the p'atient's symptoms? Could you please discuss the supporting and negating evidence for each hypothesis.

• Clinicians'


At this stage, the primary diagnostic hypothesis was that of l umbar instability. Supporting evidence for this hypothesis included : the history of multiple episodes of LBP associated with only minor or even no precipitating events • worsening of symptoms with inactivity and relief with movement over 24 hours • pain reduction fol lowing chiropractic treatment in the past but with diminishing returns. •

The sole negating evidence was the bilateral presen­ tation of the lower extremity symptoms. The main competing hypothesis was a central disc herniation. This hypothesis seemed IU<ely consider­ ing the bilateral presentation of the patient's symp­ toms. The reported worsening of symptoms with f1exed postures (sitting) was consistent with this diag­ nosis. In addition, the use of crutches to assist with ambulation seemed to indicate the profound muscle wealmess one might associate with a massive central disc herniation. The patient's positive response to methylprednisolone also supported this hypothesis. Initia lly, the report of urinary problems possibly appeared to indicate a central disc herniation, but subsequent questioning determined that the patient did not have frank bladder dysfunction. Evidence that tended to negate this hypothesis included the mechan­ ism of injury. In a healthy individual, a disc herniation would require a large amount of force, such as com­ pression through a llexed spine or a lifting injury. In this patient's case, a round of golf seemed to be insuf­ ficient to produce an injury of this magnitude. Furthermore, the patient did not report any kind of sensory disLurbance, numbness or paraesthesia, which one might expect "\lith a herniated disc compromising neural tissue.

• Clinicians'


At this point, the major pathobiological pain mechan­ ism considered was nociceptive. In keeping with an initial hypothesis of instability, mechanical noci­ ceptive pain seemed probable. The inability to exercise the proper neuromuscular control over the available range of motion can result in the deformation or tis­ sues, causing pain. In addition, this mechanical noci­ ceptive pain response may lead to chronic adaptive pain and an affective component to the condition as the patient avoids activities that are known to provoke pain. The affective component to the disorder m ay result in fear-avoidance of activities that the patient suspects will exacerbate his pain. Did you consider that psychosocial factors may have been contributing to the patient's current and/or previous episodes?

• Clinicians' answer No. The patient was referred to the clinic by a ther­ apist near his home. It was this therapist's opinion that the patient's problem was not related to psychosocial issues, but that he had been misdiagnosed. In add­ ition. the patient travelled a long distance and pro­ vided h is lodging at his own expense. The patient was also self-employed , working in his family's business. He was not l itigating and no avenue of secondary gain could be identitled. He was well-educated and seemed content with his employment and socio­ economic status. During the interview, his affect, mood and responses were all appropriate. His pain diagram was appropriate in that the source of pain was most likely anatomical and the diagram did not indicate an increased level of psychological distress. The area on a p ain diagram that a patient marks can be related to their level of psychological distress (Margolis et aI., 1 98 6 ) . In this patient's case, the area marked was

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relatively small and specific. Finally, it is not uncommon that patients with psychosocial issues have an ele­ vated numerical pain rating. This patient's rating was only 2 on a 1 0 point sca le.k

Clinical reasoning commentar y Despite the 1 3-year history of lumbopelvic pain and numerous health practitioners consulted. the clin­ icians have not erred in their reasoning by automat­ ically assuming that psychosocial impairments would be significant factors in the maintenance of



The physical examination began with an assessment of the patient's pelvic landmark symmetry via palpa­ tion and with the pelviometer (Piva et a I . , 2003), a device for measuring iliac crest level in the standing and sitting positions ( fig. 4.2). This revealed a high right iliac crest and a high right anterior su perior iliac spine ( ASIS) in comparison with the left side. The left PSIS and right PSIS were determined to be even. A standing nexion test was then performed, with the examiner palpating both PSIS while the patient Oexed forward from an upright position. With this test, a posi­ tive result occurs when one PSIS has a greater overal l excursion than its cou nterpart i n relation t o its start­ ing position. The side that has the greater excursion is regarded as being hypomobile because the il ium and sacrum have moved as a unit (instead of moving sep­ arately as per normal). The standing Oexion test was found to be positive on the right, whereas a seated Oex­ ion test was found to be positive on the left. Active lumbar Oex ion, extension and both direc­ tions of side bending were non-provocative. There

Fig. 4.2

this patient's symptoms and associated activityl participation restrictions. Although, on the one hand. such impairments were obviously consid­ ered and tested for during the subj ective examina­ tion, it is clear that l ittle or no supportive evidence for a psychosocial hypothesis was thought to be present. Biased thinking. on the other hand, could have led to such an assumption bein g accepted (despite the evidence to the contrary) and inappro­ priate psychological management being imple­ mented. possibly at the expense of appropriate physical management.

Pelvi ome te r f or measuri n g i l ia c crest level in

the stand in g and sitt in g p ositi ons.

was a slight deviation of the trunk to the left of mid­ line with forward bending. David was able to heel and toe walk without evidence of weakness in either the dorsiOexors or the plantarOexors in both lower extremities. Muscle strength in the remaining major muscle groups of the lower limbs was tested and found to be 5 / 5 . The knee and ankle j erks were brisk and bilaterally symmetrical. Straight leg raise (SLR) was assessed and found to be less than 70 degrees bilaterally. The end-feel suggested that the limitation was secondary to insufficient hamstring length and there was no provocation of LBP or other symptoms, as might be expected with restricted neural mobility. The FABER test (passive Oexion, abduction and external rotation of the h ip j oint) was performed as a quick screening test for the hips and reproduced anterior groin pain bilaterally. In add ition, the lateral aspect of the knee ( both left and right) failed to approximate the table when the patient was put into the FABER test pOSition. Internal rotation of the h ip j oint in neutra l (0 degrees hip Oexion in prone lying) and also i n 90 degrees hip Oexion (in sitting) was then examined passively. There was significant limitation of internal rotation motion bilaterally i n both of these positions. Provocation and accessory mobility test­ ing was performed by mobilizing from the sacrum through to T I l in a posterior to anterior direction. The vertebral joints in the thoracolumbar region were found to be generally hypomobile. A t this point a measurement of David's chest expansion was made.

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A tape measure was circumferentially wrapped around the patien t' s chest at the nipple line and meas­ urements were taken at maximal exhalation a nd i nhalation. The chest expansion was fou nd to be less than 1 cm. Assessment of the passive range of motion

(PROM) for shoulder nexion revealed significant limi­ tations bilaterally. No fu rther physical examination was carried out at this stage.

R EASONING DISCUSSI ON AND CL INICAL R EASONING COMMENTARY What was your interpretation of the pelvic joint exam ination findings? How much importance did you place on the observational tests, particularly considering their reliabil ity and validity! What is the mechanism by w h i c h the ASIS was high but the PSIS was even!

• Clinicians' answer The i nterpretation of these findings was that the patient was not actually describing a lateral list, but rather a torsion of the pelvis. Normally a com­ posite of tests is used to diagnose il iosacral or sacro­ iliac jOint dysfunction . The tests used in this case were the comparison of variolls pelvic landmarks with the patient standing, and also with both the standing ilexion and seated nexion tests. All of these observa­ tional pelvic tests h ave been shown to meet an accept­ able level of rel iabi.l i ty (NIOSH. 1 9 8 8 : Piva et aI., 200 3 ) . The more of these tests that are positive (abnormal lI nding), then the more evidence there is that the patient has a pelvic obliqu ity (sacroiliac jOint dysfu nction or leg length discrepancy). Furthermore. when three out of four tests agree that there is a pelvic component to the patient's problem, the weight of the findings indicates that one can effectively and accurately intervene. A leg length inequality will cause the appearance of a high i liac crest, ASIS and PSIS on the side ipsilateral to the long leg. A concomitant posterior rotation of the inominate (fixation at the iliosacral j oint) on the same side as the long leg will cause the ipsila teral iliac crest and ASIS to appear even higher. while both PSIS may appear to be even.

What weighting did you give the previous diag­ nosis of a her niated disc? What clinical features at this stage in the examination supported and refuted this explanation!

Clinicians' answer Not much weight was given to the herniated disc diagnosis provided by the orthopaedic surgeon. A central disc her niation would be the only possible log­ ical explanation for the bilateral symptoms. NotClbly, the behaviour of the symptoms was not consistent with this diagnosis. The patient complained of n ight pain while recumbent, a finding inconsistent with a d isc herniation. Recumbency w i l l usually provide some relief from symptoms, as the spine is unloaded. In addition . the patient's constant 2/10 pain rating suggested that the symptoms were not signitkantly affected by any position or movement. A patient suf­ fering from a disc herniation will likely report radi­ ation of symptoms with sagittal plane motion: however. this patient's symptoms were generally constant (although the symptoms were sli ghtly worsened in a flexed or Sitting posture). It is also not consistent with a disc hern iation that no position was reported that afforded a ny significant relief. Usually a patient whose symptoms are caused by a disc herniation can nnd some position of comfort, or some mechanical bias to the behaviour of the symptoms. The fi ndings of negative SLR testing and myotomal examination, in add ition to pain-free and full active range of motion of the lumbar spine, also tended to. refute this hypothesis.

Did the physical examination provide any further information to suppor t or refute your p r imar y diagnostic hypothesis of lumbar i nstability?

Clinicians' answer Some further supporting evidence for the lumbar instabi lity hypothesis was provided by the presence of trunk deviation during forward bending.

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However, several other findings tended to negate this hypothesis:


the lack or general muscle Ilexibility (limitations of SLR and FAB ER test motion) • normal lumbopelvic rhythm with forward bending • the lack of joint movement with posteroanterior mobility tesling of vertebrae.

• Clinicians'


Measurement of chest expansion is not normally a routine part of a lumbar spine examination. W hat was the specific reason(s) that prompted you to measure chest expansion in this case?

W hy did you curtail the examination at the point you did?


The physical examination was ceased at this time because of an increasingly high degree of suspicion of ankylosing spondylitis. In particular, the markedly restricted chest expansion was of concern as it is a sign commonly found in patients diagnosed as having this disorder. A radiological examination was needed to help to confirm or exclude this provisional diagnosis and also to determine the extent of articular involvement (especially of the hip joints) if changes were found.

• Clinical reasoning commentary

• Clinicians' answer A reasonable degree of SuspICIOn of ankylosil1g spondylitis led to the decision to measure the patient's chest expansion. It is a clinically useful test for anky­ losing spondylitis because a measurement of less than 2 . 5 cm is 94% specific for (or likely to rule in) ankylosiug spondylitis. If a patient tests positive to a test with a high specificity, it is probable he has the disease (Sackett et aI., 1 9 9 7) . Therefore, chest expan­ sion greater than 2 . 5 cm would be required for a normal test result (Rigby and Wood, 1 9 9 3 ) . The find­ ings that raised the suspicion of ankylosing spondyl­ itis were: reported morning stiffness, alleviated by movement constant 2 1 1 0 pain rating over a 2 4-hour period, relatively uninl1uenced by movement • some movement was helpful, but vigorous move­ ment (e.g. yoga) worsened the symptoms • bilateral h ip involvement (marked decrease in bilateral hip passive range of motion , positive FABER test for decreased motion and bilateral limi­ tation of SLR) • reduced vertebral mobility throughout the lumbar spine and thoracolumbar j u nction.

F u rther investigations David was then referred for radiological investigation. The specilk views requested were anteroposterior and lateral views of the lumbar spine, oblique sacro­ iliac jOint views, and an erect anteroposterior view of the pelvis including the hip joints. This series was

What led the clinicians to test specifically for anky­ losing spondylitis. particularly considering t hat this condition is relatively uncommon and the patient had been previously examined by many other health practitioners (including medical special­ ists)? It would appear that the inability to ' n l ' sa t is­ ractorily the various clinical Ilndings to t he more obvious mechanical diagnostic hypotheses (e.g. lumbar instability, disc herniation, pelvic jOint impairment) led the clinicians to consider or 'sus­ pect' other less frequent disorders in an attempt to explain the patient's perplexing presentation bet­ ter. Although ankylosing spondylitis was not men­ tioned earlier in the clinical examination process as a potential mechanism/source for the symptoms. it had not been excluded either. That is, the hypothe­ sis of ankylosing spondylitis probably rose through the ranks of hypotheses as the h igher-ranked pat­ terns/hypotheses initially generated failed to with­ stand testing. The clinicians have maintained an open mind and critical outlook during the exami­ nation. resisting the temptation and avoiding the reasoning error of accepting an hypothesis that may be more prevalent or favoured but which only partially explains all the clinical I1ndings. ordered based on a high index of suspicion of anky­ losing spondylitis. Below is a synopsis of the findings detailed in the radiographic report. Anteroposterior and lateral views of lumbar spine. Essentially a normal lumbar spine. Mild straighten­ ing or the anterior margins or the vertebral bodies is of uncertain significance. While this finding may

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Fig. 4.4

Oblique view of the sacroiliac joint showing

mod erate sacroiliitis.

Fig. 4.3

Lateral view of the lu mbar spine demonstrating

mild straightening of the anterior margins of the vertebral bodies. These findi ngs are consistent with ankylosing spondylitis.

represent a normal variant. these c hanges may also be seen with early ankylosing spondylitis (Fig. 4 . 3 ) . Oblique views of sacroiliac joints. Changes are com足 patible with bilateral moderate sacroiliitis (Fig. 4.4). Ante roposterior view of pelvis. Mild to moderate hip joint osteoarthritis and moderate bilateral sacroillitis (sclerosis and joint irregularity) is evident (Fig. 4 . 5 ) . These findings led t o a request for a HLA-B 2 7 assay. The results of this test were positive for the presence of B 2 7 an tigen.

Fig. 4.5

Anteroposterior view of the pelvis showing

moderate hip osteoarthritis (white arrow) and moderate sacroiliitis (black arrow).

R EA S ONING DISCUSS ION Following the physical examination you were obviously suspicious of the presence of ankylosing spondylitis. Did you consider any other possible diagnoses!

Clinicians' answer After the physical examination. it was al most certain the diagnosis was ankylosing spondyl itis. At this

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po int. there really was no other explanation fo r the

The patient's initial repo rt of insidious buttock a nd

patient's symptoms and patterns of movement l i mita­

PSIS pain a lso added to my suspicion. as these are

tion of his trunk and l a rger joints. The radiographs

common symptomatic sites for sacroiliac joint pathol­

were ordered to add weight to the diagnosis and

ogy. Furthermore, the patient received almost complete

so that: a referral to a rheumatologist could be

relief of symptoms while on ora l steroids (methylpred­

made. There was no plausi ble competing hy pothesis

nisolone). The presence of bilateral symptoms. u npro­

that cou l d explain the res u l ts of the physical exami­

voked by any movement and in the presence of a

nation. Perhaps if you took a few I1 ndings from the

negative neurological examination, also increased the

physical examin ation in isolation . then you may be

suspicion of a systemic cause. Additional support was

able to suggest some other explanations. However. if

provided by the bilateral loss of PROM of some large

all the physical I1ndings are considered together,

peripheral joints (hips and shoulders). the reduced

along with the history and symptom behaviour, then

mobil ity of vertebrae in the thoracolumbar transition

a diagnosis of ankylosing spondylitis is strongly

region and the decreased chest expansion during


in halation. The





What clin ical feature i n itially caused you to

support to the working hypothesis of ankylosing

become suspicious of a syste m i c inflammatory

spondylitis. In particu lar. bi lateral sacroiliac joint


involvement (sacroiliitis) is pathognomonic for anky­ losi ng spondylitis and i s a radiological prereq uisite l'or its diagnosis. The bil ateral sclerotic cha nges of

• Clini cians' answer

the hip joints in a patient of this young age a lso

The long history of symptoms without a preci pitating

provided weight to the hypothesis. as in one-third

event and the insidious onset of symptoms at j u s t

of cases of ankylosing spondylitis there is involve­

17 years of age, a s well a s t h e constant natu re of

ment of the h ip and/or shoulder joints (Koopmcl!1 ,

the symptoms. a l l tended to initially raise suspicions.

1 9 9 7 ).

t h a t t h e bu ttock p a i n w a s n o longer present. H i s physical examination fi nd ings were also un changed David was subsequently referred to a rheumatologist

from his i nitial consu ltatio n . It was decided to treat

near his home. On his follow-up visit 3 weeks after


commencing medical ma nagement for ankylosing

tion and a reduction of his pelvic land marks was

spondylitis the MOQ score was

obtained. In other words, the pelvic obliquity was no

1 8 % and his pain

ili osacral

j oint



ma nipu la­

intenSity was a constant. unvarying 1 / 1 0 on the

longer present a nd his pelvic landmarks were now

VAS. The pain diag ram remained unchanged except

symmetrica l .

� IJ -


You administered a


as part of you r

examination and fol l owing t h e patient's referral to a rheu matologist.What particular i nformation

• Clinicians'


The MOQ was admini stered in part to gather i n for­

were you seeking with this test and how did you

mation in lieu of asking q uestions d u ring the subjec­

use that i nfo rmation? Do you use it i n stead of

tive examination. and in part to assess the pa tient's

asking certain questions in the su bjective . exam i nation?

progress after being treated by the rheumatologist. A comparison of the initial and fol low-up MOQ

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results also gave an insight into which activities were still difficult for the patient to perform and which activities were now easier. This information helped to guide the physical examination at each appointment. Many practitioners would be tempted to categorize a patient with a 1 3 -year histor y of LBP as beyond physical intervention and

level of 9-10110 and yet be in no obvious cardiovas­ cular d istress, with normal heart and breathing rates evident. In the end, this patient could be di agnosed. Perhaps it took time [or his pattern of limited motion to emerge to the point where it was recognizable. It is likely. how­ ever. that in the past this patient olTered clues as to his underlying condition that went unnoticed.

requir i ng psychological management. What led you to pursue a physical diagnosis despite the failure of numerous cl inic ians in the past?

• Clinici ans' answer This patient travelled a considerable distance at his own expense and on his own initiative and presented as a straightforward patient seeking help. That is. the patient's physical limHations as found in the physical examination were consistent with his reported level of disability (as determined by the MOQ score) and with his level of distress ( as indicated by his pain diagram and numerical pain score). Notably. his pain diagram. pai n VAS rating and MOQ score were all reasonable. The patient's pain diagram was best described as being consistent with a nociceptive d isorder, i . e. he did not complete the diagram i n a non-anatomical pattern with l arge areas marked with multiple descriptors, as is common [or the patient in psychological d istress. His MOQ score was 46% a n d we lind that most patients in psychological distress will have a score of 70% or higher. Finally. his pain VAS rating matched his demeanou r and apparent level of distress. Usually patients in psychological distress will claim a pain

• Clinical reasoning commentary Two particularly important aspects of the reasoning illustrated throughout this case are the use of screening questions and the combined application of patient questioning and questionnaires to acquire infonnCltion. Screening questions were used to obtain a full picture of the patient's symptoms. behaviour of symptoms. history. possible non­ musculoskeletal sources and potential psychosocial factors. While patients wiU volunteer what they feel to be important. i t is critical that manual therapists thell screen further in order to gain a complete understanding or the person's pain experience. In this case. questions regarding precautions and con­ traindications 10 physical examination and physical treatment (i.e. red Ilags suggestive of sinister pathol­ ogy) were essential. Similarly. screening for yellow. blue and black flags. as discussed in Chapter 1 . are important to identity aspects in the patient's pre­ sentation that may represent obstacles to recovery, either as a manifestation of a central pain compo­ nent or highlighting that the patient may be at risk of developing chronic pain.

References Delitto. A.. Erhard. R.E. and Bowling. R. W. ( 1 995). A treatment-based approach to low back syndrome:

pp. 187-204. Manchester. U K : Manchester University Press.


Koopman . W.J. (1997). Arthritis and

identify ing and staging patients for

Allied Conditions: A Textbook of

conservative treatment. PhySical

Rheumatology. 1 3 th edn. Vol.

Therapy. 75. 470-489.

London: Williams &Wilkins.

Fairbanks. J.C.To Cooper. J .. Davies. J. G .

Piva. S . R . , Erhard. R.E . . Cbilds. J.D. and


Margolis. R . B . . Tai l . R.C. and Krause. S.).

G. (2003). Reliability of measur­

ing iliac crest height in the standing and sitting position u sing a new measu rement device. Journal of Manipu lative and P h ysiological Therapeutics. in press. Rigby. A.S. and Wood. P.H.N. ( 1993).

et ill. ( 1 980). The Oswestry low back

( 1 986). A rating system for use with

pain disability questionnaire.

patient pain drawings. Pain.

Observations on diagnostic criteria for

Physiotberapy. 66. 2 7 1- 2 7 3 .

24. 5 7-65.

ankylosing spondylitis. Clinical ,Uld

Hudson-Cook. N. . Tomes-Nicholson. K .

N10SH ( 1 988). Low Back Atlas o f

Experimental Rheumatology. 1 1 . 5-12.

a n d Breen. A . (1989). A revised

Standardized Tests and Measurements.

Oswestry disability questionnaire.

Washington. DC: US Department of

Rosenberg. W. and Haynes. B.R.

In Back Pain: New Approaches to

Health and Human Service. Center for

( 1 99 7). Evidence-based Medicine: How

Sackett. D.L.. Richardson. S.w..

Rehabilitation and Education

Disease Control. National Institute lor

" 0 Practice and Teach EBM. Edinburgh:

(M.D. Roland and J.R. Jenner. eds.)

Occupational Safety and Health.

Churchill Liv ingstone.

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Unnecessary fear avoidance and physical incapacity in a 55-year-old housewife Louis Gifford



Lara i s a well-preserved 55-year-old woman. She is

Lara has a chronic pain problem relating to her back

married to Raymond, who is an arch itect, and they

and legs, but in particular to her feet. She has pain in

have one son who is a general practitioner. They are

both feet. but also pain and dysaesthesia lO both legs,

we l l off and have a lovely home in a very pleasa n t

and pain in her right groin, buttock and lO the dle of

region of rural England.

her back (Fig. 5.1). She also has intermittent problems

Fig. 5.1

Body chart illustrating the patient's symptoms.

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in the low thoracic region and at the base of her neck, and she frequently gets headaches. Lara came 2 00 miles to see me. She was recom­ mended to me by two physiotherapists who had been working with her. She was p leasant on the phone and

said that she was desperate. I inter viewed, examined and began her management in two sessions spread over 2 days. The first session, which was entirely interview, took 2 hours, while the second lasted about 1.5 hours.



You decided to spend the full 2 hours of your first appointment entirely on interviewing this lady; this clearly indicates the importance you place on this initial session and on the information you will obtain. Could you briefly outline the broad aims of your initial interview and how you use this information to guide your subsequent physical examination and management.

• Clinician's


There is no doubt that complex long-standing problems take time to understand fully. The broader more bio­ psychosocial approach that is taken here requires a full appreciation of patients' problems and the way in which their problems have affected them and those around them. Interview, and discussion during interview. is also a very powerful and important part of the management process. It provides the information base that clictat�s the best direction in which to proceed and it reassures the patient that I understand the problems that they are facing, as well as the nature of the presentation, There were several key aspects to the initial interview. • To find out about her situation now compared with

how il' had been before the problem started. In par­ ticular, to find ou t how much she does physically in comparison to the situation previously. This gives an understanding of her disability level and some idea of shorter and longer-term goals. • To find out what she feels is wrong, what the pain means to her, and what she feels about the future. • I also needed to find out about her expectations of me and what she was expecting from our sessions. Much insight is gained here with discussion of pre­ vious treatments and investigations, treatment effectiveness, and how messages and information given have been interpreted. • I needed to feel comfortable that no serious condi­ tion was present that would be more appropriately managed within or alongside some form of medical

intervention. Information here may lead to appro­ priate physical testing later. • I wanted to get enough information so that together we would be able to plan a way forward. • I needed enough information about her symptoms to be able to understand her problem in terms

of pain mechanisms and all the current physical and any 'emotional/cognitive/psychological' issues relating to the problem. • It is necessary to have a full appreciation of all psycho­ social factors that may impede management. With respect t o your aim to ensure that no serious con.dition was present, were you concerned/worried at this stage that her bilateral lower limb symptoms could reflect spinal cord involvement?

• Clinician's answer Not really, although it is always a possibility and should always be entertained in every patient. Important 'spe­ cial questions' and physical/neurological tests should never be left out. however confident one feels. The rea­ son for my confidence here is threefold. First. patients with chronic pain l ike Lara have usually been seen by many doctors and specialists and have often been thoroughly biomeclically screened already.' Secondly, if there was signillcant spinal cord involvement, clues should be picked up during history taking. Thirdly, bilateral lower limb pain is not uncommon in many chronic pain states and may be a reflection or central proceSSing/central mechanism factors rather than gross or franl< cord pathology.

Clinical reasoning commentary

The clinician's account of the 'broader more bio­ psychosocial approach' he takes with this sort of complex, long-standing problem is consistent with

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what Mattingly

(J 99 1) has described in the clinical

reasoning literature as attending to the patient's 'i1lness expericnce·. As discussed in Chapter 1. a

Main et aI.,

2000; Malt and Olafson. 1995; Strong. 20(0).

1995: Watson.

The clinician's rderence to for potcnLial

(Le. precautions and contraindi­

patient's illness experience. or what is synonymously

serious conditions

described as 'pain experience' in the pain science Iiter­

cations) and attempting to understand the patient's

aturc. refers to the elTects patients' problems have

symptoms in terms of pain mechanisms (Le. patll0-

on thcm. and those around them. psychosocially.

biological mechanisms) reveals a structurc to his

Understanding thc context. also called 'narrative rea­

knowledge and thinking consistent with the hypoth­

soning' (Fleming and I\IIattingly. 2000: Jones et al.. 2(02). requires attempting to undcrstand the patient

esis categories discussed in Chapter 1. This is not

as a person, including their pcrspective of the prob­

thc development of these categories (Gifford. 1997:

surprising given he has personally contributed to

beUds. desires. motivations.

Gifford and Butler. 1997). but it also highlights how

emotions. dc.). the basis of tbeir perspective. and how

a framework. as prOVided by categories of hYPoLhe­

the problem is affecting their life. Understanding the

ses. can assist in organizing ooc's knowledgc and

lem (e.g. understanding.

person. in addition to the problem. as identilled by the

guiding examination and reasoning. The clinician's

clinician as a kcy aim of his interview asscssment. is


increasingly being recognized as a signi!1cant variable

together we would be able to plan a way forward' is

influencing patient outcomes (Borkan et

al.. 1991;

Feuerstein and BcaWe, 1995; Lackncr et al.. 1996;


gaining sufi1cient information



testimonial to the 'collaborative reasoning' approach to his assessmcnt and management.

was markedly worse following it. She regretted ever

Initial assessment interview

having the surgery and her husband added that he

Lara's husband accompanied her for every session. She met me with a smile. but she moved very stiff ly sighed easily. She sat bolt upright. back in extension. knees at right angles and together. and her hands rested on her thighs in a very symmetrical and stylized way. The history of Lara's problem can be summarized as follows.

believed that her problems really stemmed from the operation . He was notably disgruntled about it. She recalled that her low back was agony at the time of the operation. but that it 'more or less' cleared up once she got moving afterwards. 3. After a further






returned. again for no apparent reason. This time the pain had increased its area to include the low

1. About 5 years ago. she had a fairly nasty low back

right buttock. The physiotherapist told her that the

problem. which she was told by her physiotherapist

bulge was likely to have increased and was starting

was a disc condition. There was no history of any

to irritate the sciatic nerve. She said that the thera­

injuring incident and in the past she had only suf­

pist went through all the postural and movement

fered minor. odd back pains that lasted for a few

'dos and don'ts' and some similar previous exer­

days. This episode recovered with repeated exten­

cises. As well as giving the exercises. the therapist

sion exercises in one week. I asked Lara if she went

treated her using 'pressures on the back' and ultra­

back to 'normal' activities after this and she replied:

sound. She remembers often feeling very stiff get­

'The therapist helped me understand about fluid

ting off the couch after treatment and that the

movement inside the disc and that bending pushed

exercises often left a lingering pain further down

the fluid backwards and made the disc bulge

her right leg. After 10 treatments over 6 weeks.

towards my nerves. She also taught me good pos­

treatment stopped. She recalled the physiothera­

ture to prevent this happening. As a result all the

pist saying that the disc would be healed and that

pain went. but in order to be careful of the fluid

further treatment was unnecessary. I asked Lara if

t stopped most of the gardening and have always

she had felt better. to which she said. 'To be honest.

been very careful with any back bending.'

I felt quite depressed: my movements were better

2. Eight months later. Lara had a hysterectomy and

but my pain was much the same and I had some

colposuspension (remodelling of the vagina) oper­

new rather odd feelings in my right thigh and

ation. She had complained of some urinary leakage

calf. which t was also starting to feel in my other

prior to this operation and noted that the back pain

leg. The overall intenSity of the pain was perhaps

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slightly less, but 1 was getting worried and it was starting to really trouble me at night.' 4. Lara was advised to see a local chiropractor by a close friend. She was diagnosed as having four major contributory problems. These were described as facial distortion ( 'some sort of jaw distortion'), C2 fixed in a left rotated position, unequal leg and arm lengths and what the chiropractor described as the worst sacroiliac (SI) blocking he had ever seen. 1 asked Lara how she had felt about that? She said. 'I remember feeling pleased to start with, that he had found something, he seemed very confident that it would all be put right very easily. Later on 1 started to dread going. when 1 think about it now 1 felt that he started to make me feel that the lack of progress was my fault. 1 also started to worry that the things he said were wrong, were impossi­ ble to overcome. By the end I got worse and stopped going.' Treatment involved a series of regular but very quick adjustments to her head and neck and some 'pressing on the roof of her mouth ' . Lara was warned t o stop a l l swimming s o as not to upset her SI jOint: 'He told me to stop the physio­ therapy exercises and concentrate on my neck posture.' 5. A further 4 months later, Lara's doctor referred her to an orthopaedic consultant after radiographs revealed modest degenerative changes. 'He said that I had normal wear and tear on the X-rays but there was the possibility of spinal stenosis. 1 had a scan that revealed moderate disc bulging at L5-S1 and no signilicant stenosis.' What happened from there? Lara said, 'I remember feeling very empty, very tear­ [ul and almost embarrassed to start with. He made me feel as if I was making it up, I remember the com­ ment he made, "you've got the same back as every­ one else of your age on this earth", and then he said, "the best thing you can do is 100 sit ups a day and go swimming". About a week later, 1 started to feel very angry that! hadn't been believed, but even my hus­ band seemed to side with his view-when he came in from work his fIrst words were usually, "have you done your sit-ups?".' 6. Through the next few months, Lara's doctor treated her for mild depressive disorder with amitriptyUne (tricyclic antidepressant). She was also given 'pain­ kiUers' (ibuprofen: non-steroidal anti-inllammatory agent) and co-proxamol (dextropropoxyphene hydrochloride plus paracetamol: compound opiate analgesic).

7 . Within a couple of months, Lara started to suffer





from stiffness in the back o[ the thighs on bending. She also had low back pain. buttock pain and lumbar stiffness. In desperation, she returned to her physiotherapist, who concentrated on the disc bulge. She had eight tTaction treatments, which helped to start with, but pain soon returned. In addition, she was given a corset to wear all the time. Lara could not remember any exercises being given that were not stopped because of exacerba­ tion of the pain. She returned to the chiropractor. who 'cracked' her neck and adjusted her SI joint. After four treatments and progressively worsening pain, the chiropractor referred her back to her GP, who organized an appointment with the local rheumatologist. Lara saw the rheumatologist 2 months later. By now she was only waUdng around the house, rarely went out of doors and had stopped all social engagements. Her doctor son was keen for her to see a psychiatrist. 'I was starting to think that I had something that no one else in the world had ever experienced, and that because it was so new and nothing could be found to reasonably explain it, the only rational way for doctors to see me was in terms of some kind of madness! Even my son was seeing me as a mental case. The rheumatolo­ gist said that I was "atypical" and that I did not have any j Oint rheumatism. He actually took me seriously. listened and arranged for some blood tests. Once the results came through negative, he referred me to the local pain clinic. Here, I was given acupuncture and TENS (transcutaneous electrical nerve stimulation). After three treat­ ments, I had terrible pains in the balls of my feet, which the physiotherapist said was a good thing! But the pains got worse and worse and she then referred me to hydrotherapy. She said that I had tight nerves that need moving and stretching.' The hydrotherapy was the first step towards some improvement; Lara enjoyed the movement in the pool and the pain was masked by the warmth . She said she felt very safe moving in the pool and after 4-5 weeks found that she was able to do some simple back exercises lying down at home. She made further gains using the Alexander tech­ nique (Barlow. 1981). She continued through early the following year 'managing' reasonably well and even getting to

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about 70% of normal for several months. Lara contlnued with physiotherapy and the Alexaoder technique. Physiotherapy she described as 'lying on my tummy for 20 minutes while she loosened me. then some stretches to my legs and ultrasound on my feet. I had four major exercises. Tightening my stomach for 5 seconds ten times three times a day. then the same but also tightening my buttocks at the same time. holding this tension and arching and flattening my back 1 cm while I was sitting. and then lying on the noor and stretchillg my leg up the door frame. The main message was that my back was unstable and that muscle tone had to be

increased to prevent it slipping out of place. I was also instructed to never bend without tightening my stomach.' 12. Five months later Lara suffered a severe setback in pain and also had treatment for depression again. 13. Lara was referred to a neurosurgeon 2 months later. who offered to do a sympathectomy. Her comment was: 'How can I go ahead with an oper­ ation when the man I saw didn't even examine me. peered at my notes. scans and X-rays. asked two questions about my cold feet and said that my only chance was to have an operation that cut nerves to improve my leg circulation?'



What were your thoughts regarding the history of Lara's problems! Include your thoughts on the previous management.

• Clinician's answer If you really follow what happened over time. it is an unfolding story of disastrous management that sequentially reinforced the notion of structural weak­ ness and abnormality and fear of further damage; this resulted in progressive disability with psychological distress and depressive symptoms. All practitioners have been very structurally based in their thinking and have made no attempt to understand or take on board the patient's thoughts. beliefs. attributions and feelings regarding the nature of the problem. Little has been done to allay Lara's fears and rehabilitate her back to a fuller potential with increased physical confi­ dence. Therapists appeared satisfied that pam relief was an adequate outcome. Also, common to many similar patients. doctors dismissed the problem as triv­ ial and inferred mental wealmess on the patient's part. with the unhelpful end result being the conclusion that the patient has a psychiatric disorder. It is worth noting that the therapists/doctors who have lTeated Lara to date have created: • an obsession with upright posture: partially respon­

sible for creating unrealistic avoidance and struc­ tural fear. or behaviour patterns caused by the fear created by therapy • fear avoidance beliefs and behaviour. created dis­ ability/loss of confidence; this is the result of most

therapists using a 'wealc!vulnerable structure' focus and not helping the patient actively and gradually to restore confidence in spinal movement and back strength alongside their treatments • an unnatural overfocus on the body during move­ ments; instructions like 'never to bend without tightening the stomach' reinforces structural weak­ ness perception. movement avoidance, and tension with movement. Normal movement should even­ tually be trained to be thoughtless movement but pain-focused treatment reinforces a 'back off ' move­ ment strategy • confusion and conOicting information: doctors and other clinicians have been adopting a blinkered view of the problem specific to their area of interest. Specifically please comment on the key activity/participation restrictions and associated impairments you hypothesized would need to be addressed and the dominant pathobiological pain mechanism pattern you felt was emerging.

In the 'psychological/mental' impairments hypothesis category. it is clear that Lara is upset. unhappy. dis­ tressed. frustrated, and possibly even angry. There are also many very unhelpful beliefs aod attributions about structure and cause that will need to be add.ressed and overcome before a gradual functional improvement approach can be started (especially those relating to bending). A thorough examination and careful explanation of pain mechanisms would be a useful start in the process. Highlighting structural

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integrity and soundness following examination would be important. It is likely that Lara will have altered movement patterns and significant apprehension pedorming many movements. A great deal of tissue testing is likely to find widespread abnormality. In particular. lumbar Ilexion and lumbar Ilexion activi­ ties may need careful addressing. It would be unwise to try and be specinc about the pain mechain sm(s) consequent neuroplastic changes in nervous system input, processing and output pathways/networks. the weak and deconditioned tissues. possible minor or moderate degeneration. lack of normal movement patterns and the psychological and social consequences of the whole episode. A single lesion approach to well­ established cbronic pain states like this one has to be. at best. extremely cautious. A broader biopsychosocial model that incorporates multidimensional and multi­ level thinking for assessment and management is prob­ ably the most desirable option (Gifford. 2000a. 2001. 2002a; Main and Spans wick. 2000; Waddell. 1998). Importantly. this does not preclude focussing on spe­ cinc physical impairments at some time in the manage­ ment process. Allocating a specific pain mechanism in this type of patient is probably detrimental in that it makes thoughts linger in a focussed way and misses a far big­ ger picture. A sbift in focus to disability (Le. activity and participation restriction) management is probably the Singularly most important issue. Clearly though, altered. or maladaptive, central processing of sensory and motor information, central generation of pain. maintained peripheral sensitivity, peripheral nerve hypersensitivity and all output mechanisms have a role in presentations of this type. The message is that there is no specific single source targetable by passive therapy interventions. By working on the patient's

thoughts and beliefs. alongside graded return of phys­ ical function and confidence, we will actually be work­ ing and manipulating neural pathways responsible for the pain and disability problem (Gifford, 2000b). A key thought is that inputs that improve things like self­ emcacy. patient sense of control and understanding. levels of distress, physical function and goal achieve­ ment will have positive neuroplastic effects that will have repercussions for the health of the whole organ­ ism (see Gifford. 2002b; Lawes. 2002; Roche. 2002).

Lara flfst saw me the following month. The follow­ ing summarizes the current situation and other perti­ nent information to her condition.


Family history

Father fine, mother diagnosed as having spinal stenosis in last 2 years (86 years old). Mother always grumbled about her back and never did any Ufting. She also never did any walking or kept fit. Lara has a brother 63 years old. very inactive with a long-standing bad back.

Cli n i cal reasoning commentary

A key aspect of experl reasoning we wish to draw readers' attenlion 10 here is the clear iIIuslration of the c1inician's thinking occurring on multiple levels. Recognizing apparent psychological compo­ nents. activil-y restriclions anc! physical impair­ ments within a broader picture of overlapping pain mecbanisms has provided a basis on which man­ agemenl strategies are already heing formulaled. Despite the emerging pattern. Ihe patient's prob­ lem has not been pigeon-holed into a scenario where the pain and phYSical impairmenl arc seen to be completely driven by the psychosocial issues. Rather. management of speciJic physical impair­ ments is hypothesizeo as possibly being required. and the facilitation of 'thoughtless' normal move­ ment. consistent with motor control retraining philosophies featured in other cases in this book. is Seen as importanl in the ovemll management. Also note here. and throughout the case. the clin­ iciun uses quot<Jtions from the patient extensively. This reflects how much he listens Lo the patient and the importance he places on the patient's thoughts and feelings ahout their problems.

Lara is constantly aware of symptoms (Fig. 5.1). These rate on the Numerical Rating Scale (NRS) as 8-9 on average; 6 at best and 10+ at worst. The main prob­ lem is with the feet and back. Symptoms are described as burning. stinging. Ilickers. tightness or compres­ sion feeling. and cold discomfort. Lara describes being able to hear her feet grating and has the feeling that something inside was stuck and would not move. She describes her feet as having burning pajn yet feeling

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cold. The back produces sharp stabbing pains all the

throughout the whole leg. The low back was a con­

time when she moves.

stant problem and now the right SI jOint area 'j umps'

Her legs reel tingly and coated in cling 111m from

and often feels weale. The pain frequently moves.

groin to lower one third of thigh. There are odd

She often gets pain in the coccyx region and has a

sensations in her legs: flickering, moving, wriggling,

sharp catching pain in the rig ht buttock. She also

stinging nettles and running water sensations. All

has right grOin pain and when grOin is better, the

sensations are deep, not in the skin. There is no seg­

b uttock is worse. Lara does not complaint of loss of

mental pattern: the symptoms are deep and diffuse




Lara's body chart and this list of symptoms

more productive approach would be achieved by investi­

presents a rather daunting picture. Could you

gating, understanding and addressing the relevant

highlight your thoughts at this stage? What did

activity restrictions/disabilities/impairments. Some or

you consider were the key features in the body

the 'clues' that lead to these conclusions include the

chart and was there any further support for

chroniCity of the problem, the lack of success with

your earlier hypotheSiS regarding the dominant

interventions so far, the widespread and variable symp­

pain mechanism?

tom distribution, and the many deSCriptive terms used. A fina l corrunent here is that it is probably far more pro­

Clinician's answer

ductive to think in terms of sources of disability/activity

The body chart (Fig. 5.1) clearly shows that Lara's symp­ toms are complex, widespread, non-segmental, and not at all typical of common acute and subacute presenta­

restriction/impairment rather than sources of symp­ toms. This sh ifts thinking towards what can product­ ively be improved rather than what needs to be 'fixed' .

tions. The body chart presentation reinforces the earlier interpretations with regard to multiple mechanisms and sources (relating to input processing and output) and the importance of maladaptive neuroplastic change (central mechanisms). My main thoughts were that the only form of helpful management would be if I could

• Clinical reasoning commentary The clinician raises an important point regarding the use of hypothesis categories. By virtue of being pro­ vided with a list of hypothesis categories to be con­

successfully restructure this lady's understanding of her

sidered when exan1ining and managing patients, it is

problem and the potential of therapy to help/not help;

common for t herapists to proceed and attempt to

then I may be successful in helping her to move on.


think through all hypothesis categories from the start with every patient. This is not only cognitively too demanding and hence unrealistic, as pointed out

Given this sort of presentation, how specific were you prepared to be regarding possible

here, it also can be detrimental to understanding

sources of her symptoms at this stage?

some patients' problems. Prematurely focussing on specific structures often occurs at the expense

• Clinician's

of gaining a broader picture of the patient and


The key here I believe is thinking in terms of mul tiple tis­ sues and at multiple levels throughout, but with the central nervous system as the main player. Being spe­ cific, \o\Tith our current state of knowledge, is likely to

be detrimental to a multidimensional approach and is unrealistic. The very complexity of the presentation is enough to determine that. rather than try to grapple with hypotheses about specific 'sources' of symptoms, a

his/her problems. There are. of course, no strict guidelines that can be recommended for when spe­ cific structures should be hypothesized. Patient clues suggesting serious or sinister pathology must be recognized and immediately followed up. How­ ever, beyond that, the clinician has provided useful suggestions for when specific hypotheses regard­ ing sources of the symptoms are less useful.

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Even in nociceptively dominant problems. suc­

physiotherapy is indicated. and if so what type of

cessful management wiu usually come more from

manugement is likely to be helpful. The application


of thorough assessment and balanced reasoning.





impairments rather than specific tissues. Therapists


rarely have their hypotheses regarding sources vali­

within the broader picture of pathobiolllgical mech­





dated and allen make the reasoning error of inter­

anisms. and in conjunction with known and hypoth­

preting patient improvement as substantiating the

esized pathology. will enable therupisls to deliver

source. However. knowledge of common clinical pat­

effective management while continUing to improve

terns I()r specilk structures can in many cases assist

their understanding and expund. and evcntually

enormously the recogoition of the problem. whether

validate. their clinical impressions.

• evenings are horrid and ends up lying semisupine

Behaviour of symptoms

on couch

The main ways the symptoms occur are:

• best when half asleep

• standing still causes buroingltightness in the feet. which quickly builds in intensity; it is eased by tal,­

• has noticed that symptoms are worse when she is 'uptight'.

ing shoes off; 'releases il11l1e 1 cliately' • sitting also relieves the feet symptoms quickly but it increases the back and thigh pain. making her

Current activity levels

quickly restless

Lara's current activity levels can be summarized as:

• the low back and buttock symptoms increase Vllith sitting and Lara becomes very sore or 'raw' inside;

• swims once a week: manages gentle walking in the

the pain. when severe is tender to touch: max­

pool and about one width in total by swimming on

imum sitting tolerance is 20-30 minutes

her back

• never really free of symptoms: they are constant; if they do go it is only for seconds

• waJles 1 mile once a week if she can and walks through the pain. which spreads to toes and set­

• back pain is there all the time as a background

tles; the whole leg becomes painful when she stops

aching but when moving gives sharp jabs all the

and it is usually all stirred up for 3-4 days. with a


level of pain that forces her to rest off her feet most

• cold feet feeling improves with fast walking but walking makes pain worse afterwards

of the following day • maximum walking time is 40 minutes; prefers fast

• all symptoms aggravated by movement


• shopping in local supermarket consistently aggra­

• used to be very busy but describes herself now as

vates the pain in the feet so avoids shopping as much

90% less active than prior to the problem being

as possible (tried changing shoes. adding pads in

severe; for example. she could easily walk

shoes and different corsets-all with modest success

swim 20-30 lengths and carry all her shopping

for a short time. but now nothing helping)

5-6 miles,

bags with no problems

• when pain increases in feet and legs. the coldness gets worse

• spends an average of 4-5 hours doing very little during the day. mainly shifting from sitting to lying

• the colour of the skin of her lower legs and feet change from a blotchy/purple to a deep red when going from sitting to standing

interspersed with small household activities • most of her life is spent inside and at home: she used to be 'out and about' all the time

• night time results in some problems lying on back,

• occasionally does all the housework in a morning

with tail pain. and side lying is best: occasionally

out of frustration but pays for it for several days

wakes aware of pain but always manages to get back to sleep

afterwards • has given all hobbies up; these were gardening (reg­

• poor sleeper without meclication

ular). Hower arranging. voluntary work. painting

• copes best in the morning

Oowers and embrOidery (earlier in the year she had

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managed some pottering about in the garden but she had not done any flower arranging for 2 years) • has not been on holiday since the problem started because of fear of the problem worsening and wish­ ing she had stayed at home • has not cooked a meal for other than her husband or been out for a meal for 2 years (previously she had been very sociable, often giving dinner parties and going out with friends).

Any form of concentration has made the problem worse and makes her very frustrated and upset. When asked why she had stopped so much, Lara said that she had a fear of doing more damage, creating more pain, and of something giving or going, with days of resting afterwards. She said she felt weak; activities made her limbs feel heavy and she got very tired very easily.



There is a certain degree of stimulus-response predictability that is apparent in the behaviour of her symptoms. In your previous answers, you noted that you felt there was strong evidence emerging supporting a dominant processing pain mechanism in her presentation; however, elsewhere (Gifford and Butler, 1997) you have described a common feature of the nociceptive pain mechanism pattern is its stimulus-response predictability. Can you comment on what features of this lady's presentation alter the

keeping with the extent of tissue pathology) are the length of time the problem has been around, the severity and reactivity of the symptoms, and the lack oj' medical evidence for significant enough pathology. One would expect less reactivity perhaps from a severe rheumatoid arthritis presentation. It might be best to reason that Lara has a great deal of maladaptive noci­ ception going on and maladaptive processing of noci­ ceptive traffic in the central nervous system as well. Clinically this equates to too much pain and sensitivity for the state of the tissues: hurt does not mean harm.

relevance of the stimulus-response predictability that is apparent in her presentation!

Has any of this new information elicited any new thoughts/hypotheses regarding other pain

• Clinician's answer

mechanisms or sources!

A degree of predictability in symptom response to mechanical stress is common to a great many pain states: it is just as easy to increase and decrease symp­ toms instantaneously using physical forces and move­ ments in an acute injury as it is in chronic pain states. 'Processing', along with cognitive, emotional and behavioural responses, are still a feature of all pain, even presentations that are acute and deemed largely nociceptive in nature. However, in the more chronic state, inputs that produce a pain response may be coming from quite normal tissues as well as from tis­ sues that are in various states of 'iLI-health'-many of which presumably contain maladaptively sensitized and hence over-reactive nociceptors. Further, and central to chronic pain states, is the fact that the pain 'reaction' to physical inputs is often way out of propor­ tion to what might be 'needed' by the tissues. In Lara's case, features that tend to discourage any thoughts with regard to major nociceptive mechanisms (for which the stimulus-response pattern is more in

Clin ician's answer

Not really. There are some features that might elicit thoughts relating to circulation or even aberrant sympathetic activity: like the cold feet/legs and skin colour changes. Hence, one line of thought could be: maladaptive central processing leads to altered and inappropriate outputs, which, in turn, lead to sensory inputs and more sensations. Another side of the issue is that symptoms lU<e alterations in temperature and blotchy skin may well represent reactions of a very unfit and deconditioned body and are hardly surpris­ ing. Also, there is the likelihood that Lara's attention system has become conditioned to focus on bodily sensations, thus changes in temperature may be going on normally but, as a result of the maladaptive bias in attention towards her soma, she has become greatly aware of them. These types of interpretation are 'bet­ ter for the patient' because the message that comes . across is that improved function and fitness, decreased

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body-related worry and attention and more physical

protection Crom related muscle systems and hence

confidence may help to overcome some of these symp­

maintain their sensitivity to a high degree. Stronger

toms and sensations. Allocating blame on the sympa­

and more efficient muscles, in parallel with increased

thetic nervous system or the circulation, immediately

patient 'physical confidence', may provide a sufficient

'medicalizes' the fmdings and presents the patient

environment for a sensitized tissue or sensory system to

with a problem that has no natural or guaranteed

dampen down its hypersensitivity.

medical solution-presenting them with yet another source of worry and frustration.

Dangers come when clinicians see an altered muscle control finding as key or central to this kind of problem. This is just a small hypothesis with regard to the 'bio'

Some features of her presentation, such as her coping best in the morning, frequent sharp jabs of pain and even her preference for walking fast, could be interpreted as support for a 'postural' or muscle control problem. Do you feel this impairment could be a component of her problem, either as a possible predisposing factor to the original onset and/or as a contributing factor to the maintenance of her symptoms? Could any 'motor control' impairment that may be present be a manifestation of her altered input-output mechanisms, that is a learned phenomenon with implications as to whether and how this should be addressed in her management?

part of the assessment and needs to be attached very strongly to the 'psychosocial' part. I would be very wary of overfocussing on specific 'muscle control' issues in the early stages of patients like Lara. You ask about thoughts regarding a learnt response. The answer is very much so. Pain alters movement pat­ terns, so does fear of injury and fear of pain and loss of physical confidence. For most patients with chronic pain, these are long-standing features that result in chronically altered movement patterns, which become 'set' as new habits and for many start to feel normal. The secondary consequences to all the musculoskeletal tissues and the circuitry of movement must be vast. Thoughts like this highlight the need for reduction of fear of movement and structural wealmess, and the adoption of adequate but graduated normal functional movement patterns Crom early on. Clearly for Lara, an

Clinician's answer

essential part of her programme should involve normal

This is a good point because it really highlights the

movement patterns and normal recruitment. However.

dangers of focussing on a single 'dominant' pain

I would warn again about being overspecific and too

mechanism. While central-processing issues are so

focussed/complicated early in the management with a

important here, it is foolhardy to deny any input!

patient like Lara.

sensory/nociceptive-related mechanisms. Tissues may be unfit. deconditioned, shortened, degenerate, prone

The following pOints are important alternative hypotheses.

to ischaemic effects, have scar tissues, perhaps even have a modest inflanunatory component, etc. All

• Sharp jabs of pain can be interpreted as 'neuro­

these factors may produce a sensory barrage enough

genic'. For example, ectopic impulse-generating

to maintain surricient central activity to affect pain

sites in sensory neurons can spontaneously dis­


charge and, therefore, have the potential to cause a

An important point is that a 'muscle control prob­

sharp jab of pain. EctopiC impulse-generating sites

lem' is not a direct pain mechanism. rather it is an

can also be highly mechanically sensitive; hence

impairment that in some circumstances may influence

small movements produce massive electrical dis­

the sensory system. There are a great many of us with huge muscle controllwealmess/imbalance problems

charges and consequently sharp pain. • Coping best in the morning may relate to decondi­

who have no pain at all. However, in a weakened or

tioning; in the morning, the body has had some

vulnerable organism (Lara). minor impairments, like

rest and may be best able to cope. Clearly muscle

those relating to muscle control, poor muscle power or endurance properties, may be enough to play a part in

capacity to cope is a very likely part of this. • Walking fast may produce a 'gating' effect. In other

maintaining hypersensitivity. It seems likely to me that

words, the preoccupation with walking fast helps

the sensory nerves and pathways relevant to vulner­

to inhibit sensory input relating to pain Crom

able tissues may somehow perceive that they have little

reaching consciousness.

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• Clinical reasoning commentary

education and explanation as an aspect of skilled clini­

The signilkunce of one's orga nizution of knowledge to

cal reasoning also stands out in the clinician's caution

the clinical judgments reached is upparent through­

regarding apportioning blame to a particular structure

out these answers. The knowledge of pain mecha­

or system with a patient where such beliefs are hypoth­

nisms and their assodateu clinical fealures. linked

esized to already be contributing to her problems.


The importance of re-establishing more normal

doubt. prognosis. clearly underlies the clinician's

movement patterns is recognized but. as with involve­

with lhe implications for management and.

views. Patient information is not interpreted in isola­

ment of other systems, motor control is considered

tion but considered with respecl to the broader

within the broader framework of altered central pro­

unfolding piclure that is emerging: earlier hypothe­

cessing. Alternat'ive interpretations for conventional

ses arc supported. in t bis way. the stimulus-response

clinical features of motor impairment are put forward .

predictability common in nociceptive dominant pain

Clearly it is not possible to discern the precise inter­

states can be seen also to fil within the pattern of cen­

relationship between the patient's a ltered movement

tTal sensitization described by the clinician. Specific

patterns/muscle control and the underlying pain

nocicept ive physical impairments are not discounted ;

mechanisms within a clinical exami nation. However,

rather the likelihood of multiple pain mechanisms

so long as the alternatives are considered. as they are

is highlighted with numagement implications that

here, the manual therapist can then proceed with

include taking care to avoid overattention to any

in terventions directed at altering motor con trol and

single physical impairment. Further. the importance of.

be guided by reassessment of the relevant outcomes.

General health and wellbeing

• the Alexander technique audiotape has been help­ ful so keeps using this

Her general health and wellbeing are not good:

• has tried visualizing pain away: not successfu l .

• freq uent colds and 'flu. which talce much longer to

Patient understanding of problem and

shrug off than prior to problem worsening

attributions regarding problem

• urinary problems still disturb her • generally low and feels 'blue' most of the time; copes best in the mornings and is tearful on average once a week • worries about her problem and feels very vulner­ able physically • feels her concentration and memory are not up to what they had been: 'When you do nothing you get out of practice! ' .

Lara felt that her problem rela ted to some wealmess and instability in her back and that nerves were trapped in some way. She felt that her SI joints were still stuck and that she had pelvic torsion and leg length problems. She also thought that there was arthritis in her back. that it might be developing in her feet. and that her neck was ' weak' and vulnerable to being ' locked out'. She had no fear of sinister disease and fe lt that her mother was to blame for passing on her 'weaknesses'.

Current pain management: treatment


and medication She uses a number of pain man agement methods: • uses TENS for relief of back pain . which 'h elps a

Generally Lara copes reasonably wel l , especially in the morning, but really struggles by the end of the d ay. Her husband and family are very supportive; how­ ever. her husband displays overly solicitous behaviour

litt le' • hot showers and hot water bottle are ' comfor ting'

toward her, not allowing her to do much. She said that

• takes amitryptil ine ' for sleeping'; this is ' effective'

she had become far less spontaneous since the prob­

• takes co-proxamol and diclofenac (non-steroidal

lem began: 'Normal me is in a cage; I have been so

anti-inflammatory agent): little help but takes the

restricted physically for so long that the natural

edge off symptoms

spontaneity part of me seems to h ave disappeared ' .

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Her hus band added that 'she is not the same person at

Her thoughts about the future are sometimes posi­

aU; it's very sad reaUy ' .

tive; she feels it is curable and she j ust has to fmd the

Patient's thoughts about the future and

negative phases-'I want to die'-and been through

expectations about clinician's input

some ' bad times emotionally ' .

right therapist and therapy. Lara has been through

Lara has come with high expectations for a cure as she has been told that I teach and write articles about 'curing' chronic pain.

R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R EA S O N I N G C O M M E N TA RY How has the i nfo rmation from the interview either suppo rted or not supported yo u r previous hypotheses regarding this patient's p roblems and the dom inant pain mechanisms!

mjuring incident. Understanding or dwelling on the original mechanism o f injury may not be that helpful at this stage. It has happened; i t will have had physical origins and it has now become complex and chronic. There does not appear to be anything serious

• Clinician's answer

biomedicaJly at this stage.

The information from these sections confirms that

but vigil ance should

always be maintained. It seems that there is a family

Lara has a number of factors contributing to her activ­

history of back pain-her mother and her brother­

ity and participation restrictions. She is physically dis­

which should make one think in terms of 'genetic'

abled and deconditioned; the pain mechanisms are

predisposition and social learning/social modelling

multiple. complex and well established, and her psy­

factors. Factors like these help us to come to terms with

chological distress strongly features. It also confirms

prognosis and help us to understand j u st a few possible

my feelings about her very passive attitude to recovery,

features that contribute to the development and main­

her reliance on medical intervention, and her 'struc­

tenance of a problem. It is very unhelpful to attribute

tural wealmess' beliefs about the nature and cause of

blame on factors like these, for we can have little effect

her pain. These findings provide much baseline i n for­

on familial features or the effects of the past.

mation. I am starting to understand where she is now

As far as contributing factors in relation to main­

in terms of her physical and psychological health and

tenance of activity/participation restrictions and symp­

where she would like to return. which is important

toms, a significant percentage of Lara's restrictions

with regard to short- and long-term goals, as well as

(Le, disability) may be put down to the way she has

providing u seful starting points for discussion and

been managed and the resulting beliefs and attribu­


tions she has about her problem: for instance, the images she has been given, the contlicting messages,

Given all the information obtained to this point, what were your thoughts rega rding potential contributing factors (e.g. environmental, psychosocial, physical, biomechanical, etc.) to the devel opment and maintenance of Lara's symptoms and activity or participation restrictions (i.e. disabil ities)!

the lack of i n formation or interventions promoting health and function. and the lack of any convincing (to her) examination of structure, Other issues include ongoing high levels of pain that are poorly controlled. the widespread distribution of pain. ongoing and high levels of psychological distress. and a predomin­ antly passive/avoidance coping style with low activ­ ity levels. These are all present and are known to be strong predictors of high disability and poor outcome

• Clinici an's answer

(Watson, 2000) . Her husband's understanding, beliefs

The onset of the Original back episode. as in a great

and behaviours are also likely to be contributing to

many patients, could not be related to any specific

the maintenance of her disability /activity restrictions

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and participation restrictions and will need t o be

their own rather than bias our investigation to more

addressed (Newton-John. 2 0 0 0 ) .

detailed fmdings. More specific examinations or phys­

Many of the above factors are l i kely to have played

ical impairments can sometimes be useful and relevant

a major role in the maintenance of her symptoms too.

later in the management process. Every abnormal

Poor management leading to ongoing anxiety in rel a ­

reaction. minor movement abnormality or loss o f

ti on to the problem may create a habitual focussing

range is somet hing that can be added t o a list of find­

on pain. serving 10 enhance its accessi bility to con­

ings that could be worked on and improved. but may

sciou sness and further strengthen its neural repre­

not need to be. Most frequently, the restoration o f con­

senta tion. Deconditioning. degenerative changes o r

fident movement patterns greatly improves or even

what might be termed ' physical vulnerability' must

resolves many of the physical impairme nts that may be

also play a pa rt as welJ .

noted. The primary aim is to get a disabled human


delve unnecessarily further i nto fmding overspecific

Given the presentation that is unfolding thus far. what are your aims for your physical examination?

being active. functional and conlldent again. and not to abnorma lities that may be i rrelevant or o f little value to treatment goals-especially early on i n the manage­

• Clinician's answer

ment process.

P hysical examination has signillcance for the manage­ ment process. fo r diagnosis and for the patient. For the pa tient. we need to seek to reassure via a thorough examination. The patient must feel that a thorough exami nation has been done and that any findings have been given a reasonable explanation. It is wise always to attempt to give reassw'ing messages. rather than cre­ ate fear. Examination is perhaps one of the most import­ ant parts or t he management process: an important issue fo r patients l ike Lara is finding features that are good and highl i ghting them as they emerge. rather than searching out the bad and adrung to the worry and confusion. For manage ment we need to explore the extent o f physi ca l impa irment and make sense of i t in relation to the type of intervention offered. Diagnostic examination may have limjted value i n this type of patient w i t h c hronic pain. Clearly the clin­ ician should always be aware of any 'red flag' features of importance. Howe ver. Lara has had plenty of medical screening tests and is. therefore. unlikely to have any serious disease process. Examining patients like Lara. who have chronic pain and marked activity restriction. does not normally warrant any in-depth or focussed appraisal of mi nor impairments if a broad educational/self-management/ functiona l recovery approach is to be adopted. Here. the early focus of examination is more on observations of function and activity restriction and perhaps some of the more bl atant and relevant physica l impairments. as we ll as patterns of illness behavio ur. tension and fear in movement. and an appreciation of the extent o f the problem and the degree o f the deconditioned state. We basically need to know what the patient can do on

Clinical reasoning commentary As discussed above. it is casy to overattend to the sou rce of the symptoms i n a classic medical diagnos­ tic sense. While hypothesizing regarding symptom source is lIseful in many patient pre sentations. and here the clinician is i ncreasi ngly more certai n or a ""idely distr ibuted source to much of her symptoms. identifying the contributing factors relevant to the presenting disability often will be as i mportant. or even more important. to a successful o utcome. [n this case. psychosocial factors/impakments are con­ sidered the key contributing factors. although phys­ ical impairments. such a s the altered motor control discussed above. may also be seen as contributing factors to the maintena nce of her problems. While experience will enable therapists to recognize pat­ terns where physical i mpairment is secondary to the broader psychosocial and health/fitness concerns. as is t he case with this patient. prematurely di s­ counting or not e ven a ssessing for physical impair­ ment is a s much an error as only looking for specific phys ical impa irments \·vithout regard for the broader psyc hosocia l and health status of the patient. That i s. physical impairment can also trig­ ger or drive psycho socia l problems. a nd differenti­ ation of

the relevance of each is best ma de

through thoro ugh assessment. intervention and rea ssessment





psychosocial outcomes. An important aspect of ski lled clinical reasoning. 'which is nicely highlighted here. is t he c1inician's

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incorporation of management within the actual

Management is not reserved until some set point

examiuation. By 'finding features that are good and

when all information has been obtained; instead

highlighting them as they emerge' , the dynamic

it commences with the initi al introductions. espe­

nature of


the clinician's reasoning is evident.


the rapport




Clinica l reasoning does not occur as a series of set

and th e i nterest that is shown. and conti nues with

steps. Rather. it is a Iluid. evolving process where

the ongoing expl a nations and educat i on t ha t are









Movement analysis and testing i s not a silent or

get down onto the 110or. She cou ld not walk on tip-toes

totally therapist dominant affair. AU th e time I am

and was very unsteady walking backwards.

asking the patient what they think about the quali ty,

Lara' s husband helped her a lot in undreSSing.

range or particular strength of a movement or test. In

Lara avoided all bending, groaned a great deal and

these types of presentati on. as well as observing the

held her back when it hurt.

poor quality of many movements. I also make a point

Her standi ng posture looked fine: leg length looked

of looking for good quality or relaxed movements and

equal with no obvious major disl-ortion or shill There

may posi tively reinforce what I observe, thus begin­

was no evidence of marked muscle wasting in any one

ning a forward moving therapeutic process. Most

individual group. Her balance on either leg was poor.

examinations that these patients have had pOint out the abnormal findings, thus adding to their already negative state. It is useful to hear what the pati ent thinks in rel ation to your thoughts, and it is i mportant to i nvolve them in th e process of analysis-some­ thing that has usu ally been denied them (Sh orland.

Physi cal goal s Several physical goals could b e l isted a t this stage: • relaxed sit ting and moving. especi ally getting out of a chair, gait and negoti ating stairs • relaxed and faster/more normal walking pace

1 9 9 8).

• i mprove confidence and find a 'physical pathway' or a series of graded exercises or activities to facilitate

Initial observations and functional

tip-toe walking, backward walking, kneeling on all


fours and getting onto the n oor

Lara sat very upright, knees together and very symmet­ ricaUy poised. She l ooked tense and sh e moved very stiffly and winced going to sit and stand. She kept very still at first and talked very clearly in a slow and monot­ onous voice. Before asking her to u ndress, I asked Lar a to waU<

• independent dressing/undressing, independence from husband (he needs to be incl uded in under­ standing pain and suggested process of rehabUi­ tation) • reducing groaning and gri macing; the aim is to enjoy movement

several times the l ength of the cl inic corridor and

• im prove balance.

to go up and down some steps. She wall<ed with a

We also need to discuss and reassure Lara concerning

relatively sl ow, but normal gait. Walking was recorded as 43 seconds to do four l engths of the corridor (the corridor is about 9 metres l ong and four lengths at a reasonably normal walking pace takes abou t 20 sec­ onds) . She managed the steps with great effort; she regularly w inced and held herself.

leg length and all the other ' structural faults' she has been told abou t.

Standing examination I informed Lara: 'I want to look at some of the move­

She could get into the upright kneeling position

ments of your back and legs. I don' t want you to do

"vi th difficulty but was unwilling to go onto all fours or

anything you don't feel like dOing, I just w ant to get an

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idea of how good your movements are. We can discuss what you feel or anything you want to say as we go along, is that OK?' 1 usually stand where the patient can see me and first perform the movements to show them what I want them to do. Flexion

Flexion was about 10 degrees. When asked, 'What stops you going further?', Lara answered 'The pain and r know it will stir it up for hours'. We continued, doing and asking. Exte nsion

Extension was virtually nil: '1 hate it' .

perform. with the description 'heavy' featuring strongly again. Lara was surprised at the findings and made the comment in a rather clisconsolate voice: 'I'm more knackered than I thought I was'. 1 then commented back (it was a very opportune time to do so): l\ll this is not surprising. as you haven't been at aU active for a long time. I'm seeing someone in front of me who, like many others similar to you. is in quite a deconditioned state. You're weak and your body has become more sensitive. in part because it is so weak. [ ' 1 1 tell you more about this later. but for the time being understand that the human body has a very good capacity to get strong and healthy if its done in a careful. constructive way and in a way that you don't feel frightened. ' Tests fo r behavioural signs

Side flexion

Side Ilexion was half range and rotation was all trunk on legs with very little spinal movement. Arm and neck movements

With Lara facing me, I asked her to copy my movements as far as she wanted to move. 1 did arms above head, hand behind back, and horizontal shoulder neAlon, all standard neck movements. deep breath in and fully out (noted good spontaneous thoracic and lumbar exten­ sion and flexion here). Her arm and neck movements were full range, spontaneous and of good , smooth qual­ ity. When I asked Lara how her arm and neck move­ ments felt to her. she surprisingly replied, 'extremely difficult and they feel like lead' . She then made a spontaneous comment: 'I've been examined at least 10 times in the last few years and no one has ever asked me what 1 think or feel with the tests. It's almost as if 1 have to relinquish ownership of this body thing that 1 live in, because nobody asks, nobody under­ stands, because nobody has time to listen, nobody has heard anything. 1 think that the medical profeSSion and all the therapists are afraid of my problem .' Lumbar movement

Lumbar side gliding or side shifting revealed surpris­ ingly good quality of movement. H i p movem ent

Standing with one hand on the wall for balance, we cUd hip flexion. abducLion and extension. These move­ ments w'ere generally half range and difficult for her to

Before moving, on I did an additional two tests: axial loading and simulated rotation. Both these tests are used to indicate what Waddell terms 'behavioural signs'. These signs and the reasoning behind them are described in detail in his book The Back Pain Revolution (Waddell . 1 9 9 8). This book is strongly recommended to all manual therapists. Axial load­ ing involves slight pressure applied to the top of the patient's head with your hands. Simulated rotation aims to rotate the patient's body without prodUCing rotation in the lower spine. In order to do this, the examiner gently rotates the patient from the pelvis making sure the trunk does not twist. Trunk twist can be prevented by getting the patient to stand relaxed with their hands at their sides, holding the patient's wrists or hands against his or her pelvis, and passively directing rotation of the body. Both the tests were posi­ tive in that they provoked pain in the back. The other 'Waddell signs' are: • widespread tenderness spreading far beyond single

anatomical regions and often over many segments • distracted straight leg raise (SLR) • regional weakness indicated by weakness over many segments and a jerky or 'giving way' response: for example, weak and j erky quadriceps testing, yet the patient can walk • regional sensory change: losses of sensation where the boundaries are beyond the normal innervation field and dermatome distribution. The symptoms may include: • pain at the tip of the tailbone • whole leg pain

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• whole leg numbness • whole leg giving way • complete absence of any spells with very little pain

in the past year • intolerance of. or reactions to. many treatments • emergency

admission to hospital with simple

backache. Add itional phys ical goals

Lara needs a progressive prognm1me to restore conn­ dence and the function of lumbar and hip movements and muscles. At some stage, a programme lor the upper limbs and neck should be included. Sitting examination

I now asked Lara to sit on a low stool. I sat i n front of her. again doing the movements with her. Movements performed were head into flexion and back up, and slumping the spine. As I did the latter movement I said, 'Can you let yourself go into what I call lazy sitting, like this?' She commented back, 'I haven't done that lor 2 years-I've been told to keep upright to stop the disc bulging'. Remember that her bending was 10 degrees in standing and that her husband had helped her undress-1 had not seen her bend beyond this. I then hugged one knee to my chest and gently dropped my chin part way to my knee: 'What about this movement, or a part of it?' Lara tried and demonstrated quite smooth movement with spontaneous lumbar flexion using either leg. Importantly, I did not say something like: 'See your back is bending ' . All I said was, 'That looks good, now lets try this'. I put my leg back down, placed my hands on my knees and slowly lowered my body forwards towards my knees, saying, 'See what you can do. You have your arms to stop the movement if you are not sure and you can come back up any time you m(e. If you don ' t want to do it. that's nne.' She flexed very slowly but quite well in the spine and hips, probably about half normal range. I then looked at Lara's feet, palpated them generally and did foot movements and muscle tests while she sat with her legs dependent on the treatment couch. Her feet were cold and 'blotchy'. They were hypersensitive to palpation, particularly over the balls of her feet, but active movements were good. AU muscle tests produced giving way (a notable 'Waddell sign'). Her feet looked anatomically normal. with no evidence of swelling or degenerative changes except some slight lipping of the medial joint line of the metatarsophalangeal joint of

the big toe. Lara mentioned being aware or some crack­ ing and clicking in the ankle joint. My response was. 'Is that concerning you?' She replied. · It makes me feel that arthritis is setting in'. I responded. ·OK. that is an issue that I will put on my list of things to go inLo'. The pOint is that until a patient understands the nature of chronic pain and tissue health issues it is difficult and often unhelpful to discuss individual concerns like this. The best strategy is to listen and acknowledge all the patient's worries and concerns so that they can all be dealt with later on. Calf and quadriceps rel1exes done in this sitting pOSition were quite normal. There was no clonus and the Babinski test was normal. Proprioceptive testing in all lour limbs was normal. There was no major sensory loss to light touch. although diffuse areas of slight nu mbness around the (oot and lower leg were revealed. The key words she Llsed were. 'I know its not as it should be'.

Lying examination

The examination continued in a similar vein in supine lying. crook lying and side lying. Most tests were actively perJormed by the patient and directed or demonstrated by myself. For example. Lara performed the following active movements in lying. • Hip flexion: patient grabs her knee and pulls it

towards her. Lara was very tentative but could do it. • Active SLR: good range to 90 degrees with the oppos­

• • •

ite leg in 'crook' position. With both legs straight she could not initiate the movement. Passive testing/ assistance revealed marked pulling in the whole leg at 70 degrees ( both legs). If active dorsiflexion was then added, the pulling spread into the foot quite markedly. Active lumbar rotation in crook lying "vaS half range and tense. Active hip abduction in crook lying position demon­ strated good range. Active pelvic rocking surprisingly showed a good range of llexion, well coordinated and with no wincing! Extension was of modest range and rea­ sonably relaxed until pain came in. Leg length looked quite normal with reet together in supine and crook lying (she agreed) .

I also p u t a long ruler across her anterior superor iliac spines to assess for any pelvic torsion. Again we both

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agreed that there was l ittle d i iTerence. I even tried to

by your nervous system in terms of pain and d a nger.

get Lara to tilt the pelvis by contracting her b u ttock

I w i l l talk about it more l a ter and I have some hand­

muscles on one side and then relax: always the ruler

outs so you can go over it when you are at home . '

came back to level. This raised a lot of questions for her

A l l areas of p a i n were palpated t o establish the

as you can imagine. Rather than d ismiss the notion

extent of the sensitivity state (rather than solely using

of pe l v i c torsion (which might be quite detrimenta l ) .

it to assess for local tissue pathology or local tissue

[ commen ted : 'I w i l l t a l k about a ll this later and I hope

abnormalities). For instance, in side lying it was estab­

you will be able to see how it fits in to

bigger picture

lished that very gentle palpatory tests over the back

about the modern understanding of ongoing pain. A l l

and right b uttock a reas were excessively senSitive.


the findings here. and the findings o f those you have

indicating marked hyperalgesia/allodynia. The reader

seen in the past, need expla ining as far as possible. For

should also be aware that widespread tenderness

now, try and think of your system as having entered

palpation in atypical non-segmental patterns is one of

into a " hypersensitivity state" with all your nerves

the 'Waddell signs' ( l isted above). Again, a n i nd ication

conveying information that too easi ly gets processed

of a maladaptive central hy persensitivity mechanism.

� J -




There is some concern amongst some c l i n i cians

hypersensitiv i ty syndrome': thus, offering evidence of

that the 'Waddel l symptoms and signs' can

a marked presence of a m a l ada ptive central ized pain

lead to some patients' p roblems unfairly and

mechanism in the patient's problem a nd the l i keli­

non-usefu l ly being categorized as 'non-organic'.

hood of high levels of distress. I rather feel that the

Can you comment on how you inte r p reted this

thinki n g clinician. w ith a l l the s u bjective i n formation

lady's positive signs and the i m p l i cations it held

and the i n formation gathered from the observations.

for the management plan you were formu lating!

should be able to see the state of affa irs quite clearly without recourse to the 'Waddell symptoms and signs ' . However, they are well researched and, like routinely

• Clinician's answer

checking reflexes. they are often well worth quickly

It should be remembered that Gordon Waddeil is an

doing. If severa l of the signs and symptoms are present,

orthopaeclic surgeon whose primary concern when he

they are strong inclicators that a multidimensional

developed these tests was to prevent any unnecessary

approach is v i tal. The fact that two of the behavioural

surgery or the performance of surgery on patients who

signs are present i n Lara adds supportive evidence to

were likely to have a poor outcome. He developed the

the emerging picture that fu rther suggests a complex

'non-organic versus organic' symptoms and signs to

hypersensitivity syndrome, rather than a b iomedically

help to clistinguish between patients with back pain who

alarming presen tation.

had a specific and uncomplicated problem that was amenable to surgery and those whose pain states were

At this stage what were yo u r thoughts regard i ng

far more complex and where surgery was inappropriate.

the information obta i n ed from the phYSical

Unfortunately for many patients assessed by others, the

exami nati o n !

very unhelpful term 'non-organic' suggested that the patient's problem had psychogenic origins and was. therefore, to be discounted as real. What Gordon

• Clinician's answer

WaddeU intended from the list of signs and symptoms is

Because of the chronicity and the subjective presenta­

a great deal dUTerent from the way it has been interpreted

tion fmdings, my thinking during the physical examin­

and used . His choice of terms was very u nfortunate. Interpreted in

ation of Lara was not overdominated by thoughts

non-judgmental way, these signs

rela ting to speciflc hypotheses about pathology, sources

are very usefu l . My preference is to use them to

and mechanisms. However. key 'red flag' testi n g for

help in classifying the patient in terms of ' chronic

neurological impairment has still been done and should


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never be omitted, in my opinion. My main intention was to look at function/activity restriction (and monitor the

in pathological terms. such as ' adverse neural tension' or a Significant peripheral neurogenic mechanism. The

regions or 'sources' of the restrictions) and hence lind

symptom picture is just too long standing and too

out what she could and could not do, thus giving me

widespread to consider in an isolated way. Far better

some idea of where a process of physical recovery might

for now to label this finding as a SLR impairment that

begin or proceed. I guess that in a subconscious way

could be usefully addressed a t some stage in the

observations of movement and willingness to move in

rehabilitation programme.

different positions reveal features that con finn a feeling of structural confidence and that no major biomechan­ ical or pathological issues are present. For example, I was able to observe good lumbar intervertebral move­ ment from some starting positions in my silting exam­

Favourable ex amination movements! findings

Most practitioners focus on the negative findings:

ination. What this left me with was that her back was

the things that are wrong. While this is u nderstand­

capable of physically bending given a situation whereby

able and necessary in treatment models that chase the

fear, anxiety or the notion that the back was bending/

'sources' of a disorder, or that seek-out the impair­

vulnerable was eliminated or was being 'gated out' in a

ments to be rehabilitated, it is often worthwhile to start

subconscious way. The key is that this type of situation is

with summing up the positive aspects of the examina­

common, and, if anything quite normal. even in acute

tion for this type of chronic problem. Most of the time

back injuries where patients have an understandable fear of bending. It must not be looked upon as the prob­

these patients are presented with a rather grim sce­ nario following standard physical examinations, so

lem being 'non-organic'. Rather. it reveals the extent of

presenting some positive findings is a novel and very

fear of movemen t, but it also reveals a 'way in' to be able

useful thing for many patients. The importance of

to restore back bending confidence for the patient. By the end of the sitting examination, some of the important issues raised were:

using positive reinforcement has been emphasized by Shorland ( 1 9 98) . For Lara the positive findings were: • walking and ascending/descending stairs

• examination revealed a simple way of addressing

• side shifting in standing • bringing knee up towards chin in sitting

lumbar flexion fear/movement loss • matters relating to education about her problems,

• coming forward in Sitting

e.g. arthritis a nd cracking/clicking • education about the process o f physical recovery.

• feet movements in Sitting • all knee movements in sitting

for example, that bending of the spine is safe. nor­

• hip flexion and active SLR in crook lying

mal and necessary for a healthy spine, and that it is

• pelvic rocking in crook lying ( i.e. arching and

rounding the back)

possible to improve • areas of hypersenstivity in the feet; a graded

touch/massage programme to address this may be

• lumbar rotation i n crook lying ( Le. tald ng both legs

to one side then the other) • essentially normal neurological l1ndings, e.g. reflexes

appropriate at some stage. Note that findings Lil<e normal reflexes and diffuse low­

• taking some exercise, e.g. swimming, walking.

grade alterations in sensitivily that are out of classic nerve root or nerve trunk patterns increases confidence

Find ings that may be focussed on fo r

in the therapist's structural and physiological interpret­


ation. It also downgrades notions about mechanisms relating to anatomical structure, such as tissue integrity or peripheral nerve root vulnerablility. Also note that in the lying examin ation a 70 degree SLR with foot dorsiflexion adding to the symptomatic response could be seen as a positive sign for neurody­

Much relates to fear of movement, fear of damage and fear of pain exacerbation, as well as l ack of use and physical deconditioning: • winCing and holding with many movements and


namic abnormality or a peripheral neurogenic mech­

• unable to go to all fours or get down onto floor

anism. However. I hesitate to consider this anything

• markedly reduced lumbar motion in standing and

more than hypersensitivity relating to the neural con­

during functional activities. e.g. dressing

tinuum and central processing, rather than labelling it

• hypersensitivity over back/buttock a nd feet

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somatic perception using questionnaires. for example

• heaviness/weakness in arms/neck/legs • poor balance

the Modi fied Zung Depression Inventory and the

• poor hip movements

Modifted Somatic Perception Questionnaire (MSP Q ) .

• general lack of end-range capability in affected areas

H i g h scores o n these measures really indicate that

• giving way with muscle testing.

there may be a need for psychological input alongside

R'Camples of some important rUDctional findings (acti­ vity and participation restric tions):

the physical rehabilitation process (Waddell. 1 9 98).

• Clinical

• decreased tolerance to standing still

reason i ng commentary

The continual linking the clinician mal<es between

• decreased tolerance for sitting

examination Ilndings and implications again high­

• decreased walking d istance

Lights the dynamic nature of clinical reasoning.

• not dressing independently

Expert therapists do not wait until aU possible exami­

• inactive in the evenings

nations have been completed before lorming and fur­

• sleeping problems

ther testing hypotheses. Hypothesis generation and

• limited shopping • stopped various activities. e.g. driv ing. cooking.

gardening. nower arranging. embroidery

testing is a n evolving process commencing from the patient interview and continuing through the physi­ cal examination a nd ultimately throughout the

• general feeling of weakness and being unfit.

ongoing management. While expert therapists will

Social participation restrictions include:

have highly developed knowledge bases that enable them to recognize clinical patterns and management

• entertainment and hobbies curtailed/ n i l

implications. they arguably only reach that level of

• not been o n holiday • a significant loss from what she used to do (see

list above)

knowledge organization through a process of retlec­ live reasoning that allows them to integrate acquired biopsychosocial knowledge with clinical presenta­

Mental/psychological impairment was not fo rma l ly

tions learned from their practice. Even management

evaluated. However. it is quite clear that this lady is

in the form of deliberate responses to the patient and

distressed and rr ustrated by her predicament and is

goal setting are seen to commence within the physi­

desperate to get help in some way.

cal examination by this expert. a skill only possible







levels of depression and distress as well as heightened

when the therapist is able to think sinmltaneously and metacognitively on these different planes.

The steps that follow encourage a patient domin­ ated role i n the process of restoring physical fitness and confidence. Patients usually quickly understand There are two initial difficulties that need to be help­ fully addressed. Both relate to the patient's beliefs. First. the beliefs about the nature of the problem are very 'vuln erable/weak structure' and disease orientated. Secondly, the beliefs about treatment are orientated towards a process of finding the source or disorder and

the meaning of a deconditioned state and that lack of physical activity leads to loss of physical fitness and heig htened sensitivity.

Edu cation 1 The overall goal of the first 'education' input was to

fIXing or curing it. Lara seems to have high expectations

decrease her concern about pain me aning damage or

that I will provide her with the cure and this is unreal­

da nger. so that the process of gradual return of phys­

istic and unhelpfu l.

ical co n fidence might go ahead less hindered by nega­

A primary goal was to shill her understanding of

tive and fe arful thinking about structural damage and

the problem from a perspective where pain is seen as a

progressive disablement. This is not as easy to do as it

reliable guide to danger (adaptive/helpful pain) to one

sounds. Malada ptive pain is ju st as real as adaptive

where pain can in large par t be viewed as of l i ttle value

pain, and i t can be very h ard to believe that the hurt

(maladaptive/unhelpfu l pain).

you have has l i ttle meaning or little value. Lilce i t or

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not. patients are more likely to listen to and believe clinicians who in their minds have some kind of higb professional status. The second aim was to help Lara to understand that a passive treatment approach was inappropriate at this stage and that the best approach involved a great deal of input from her. Part of this involves a shift in emphasis from pain-focussed management to more function-focussed goal achievement. Education. therefore, involved a simple brief discus­ sion of the following. The nature of adaptive/acute pain and chronic/ maladaptive pain: the former is useful , helpful pain as opposed to useless. unhelpful pain. • A simple explanation was given for maladaptive and excessive sensitivity to movement, intolerance of prolonged posture, and tenderness/hypersensi­ tivity to touch and pressures. • The analogy was made of ongoing background pain to an annoying tune in the head all the time. i.e. the constant pain relating to abnormal nervous system 'circuitry activity ' rather than a disease or abnormality in the tissue where the hurt is felt. Explaining and discussing phantom limb pain often helps here (Gifford 1 998a. b). • The gate control theory of pain is explained (i.e. that pain normally comes and goes relative to an individual's attention and the value or meaning they may put on it). •

Reduced activity

/ ! /�

UPhOP' ' '"'" 9 h" ,"d b

Chron i c Pain '


The effect of mood on pain, activity and life in gen­ eral is discussed. This helps the patient to come to terms with low mood being normal for anyone who suffers an ongoing and seemingly non-resolvable problem. It also underlines the positive message that mood state commonly improves as the patient starts to achieve progress and gradually recover better physical function. • The effect of 'pain fear' and 'damage fear' on move­ ments, activity and life leads on to introducing a treahnent approach with a locus more on functional recovery/physical confidence rather than on getting rid of the pain or the apparent source of the pain. Patients somehow have to come to terms with the fact that pain therapies and medical interventions for chronic ongoing maladaptive pain have a very poor record of success. In contrast, approaches that focus on better physical confidence and fitness have a much belter record. ft is sometimes helpful to give a brief history of another palient who bas been successful. Giving the patient a book like Neville Shone's Coping Successfully with Pain ( 1 995) is often very helpful. • The illustration from Nicholas ( 1 996; Fig. 5. 2) was used to show the patient the way in which modern pain research has begun to appreciate the com. pJexity and difficulties that a patient with ongoing pain can have. Patients are often relieved to find that medicine is beginning to understand the impact that their ongoing pain has on their lives. and that they are not alone.

� �� �



P hysical deterioration (e g. muscle wasting,

'''"P e ss, JOint stlffness)

Repeated treatment ___ Feelings of depression . .


helplessness and Irritability


Long-term use of pain killers and sedative drug S'dc o

Excessive Suffering

L /

(e.g. stomach problems lethargy, constipation Loss of job. financial and family stress

Fig. 5.2


_ _ _ _ _ _ _ _ _ _ _ _ _ _

The common consequences of chronic pain. (Red rawn with permission of the

IASP. from Nicholas, M . K . (1 996).Theory and practice of cognitive-behavioral p rograms. In Pain 1 996: an updated review. Refresher course syllabus. Campbe l l . J . N ., ed., pp. 297-3 03. IASP P ress, Seattle.WA.)

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Lil<.e many si milar patients. Lara fou nd the inlormation very enlightening and interesting. She had many ques­ tions. and we both explored many issues that related to the hopes and lears of past management as well as issues for the fu ture. She quickly grasped the concept of maladaptive pain and that physically getting back more relaxed and normal movements would be a good start­ ing point for recovery. She was insta ntly eager to start the physical 'chaJ lenge' and we spent q u i te some time dealing with fear of bendinglnexing the spine and the natural stTCngth of the spine. even when degenerate. As with so many patients in s imilar situations she said. 'Why hasn't anyone told me th i s before about pain and movements?' An answer that can helpfully be given is that. ' I l is o n ly in the last 1 0 to J 5 years or so that science and research has started to give us a better understa nding or pa in. and it is only very recen t ly that the fu ll implications for management of pain has started to have an impact on clinica l practices'. This attempts to avoid producing any unhelpful anger with previous practitioners and treatments or advice. Pre-prepared handouts were given relating to all the above.

Baselines, pacing and incrementing Most pain sufferers like Lara persist with activities until they are forced to stop by the pain. This often i nvolves many hours. sometimes days of resting and i nactivity. In order to breal( this overactivity-underactiv ity cycle, exercises and activities are paced so that this very u nproductive p rocess is overcome. A base l ine is the number/repetitions/amount of time for an exercise or activity that a patient can manage to do every day regardless of the intenSity of the pain. This is found by taldng the average of a series of trials done over several days and then reducing the average by 2 0%. Incrementing or pacing from this baseline is done by increasing the number or time of each activity / exercise after a set period. for example weekly or every fou r days (Harding, 1 9 9 7 , 1 9 9 H : Shorland. 1 Y 9 X ) . The overactivity-underactivily cycle was explained and pacing o f resti ng was d iscussed. Exercises were recorded for reference and handouts were given relating to exercise and functional pacing and the overac tivity­ underactivit')' cycle. The follOWing exercises were used: • crook-lyi n g starting pos ition: pelvic rocking:

l u mbar rota tion;

a l tern ate leg Jlexion


progress to grasping knee or if easier do i n sitting

Starting the process

as in examination)

The last 45 minutes of the second consul tation i nvolved a focus on a series of simple exercises rela ting to the back. hip and leg. as well as two fu nctional activi ties:

• active SLR w i th non-act ive leg in crook positi o n • waU<ing up/down s t a i r s o r step-ups (whi chever preferred)

waLldng and going up/d own stairs. Concepts discussed

• sit to stand

included gradual mastery (graded exposure), baselines,

• stand i ng

pacing and incrementing the exercise programme.


pos i tion

( w ith



required): hip Jlexion/extension, h i p abducti on, one leg balance, a l te r nate calf raises

Gradual mastery/graded exposure process The term gradual mastery/graded exposure comes [rom the psychological li terature dealing with phobias

• tip-toe i n g


(wei ght


a r ms


requ ired ) . Instead of waU(ing for 2 miles i n termittently a n d w i th

(Harding, 19 9 8 ; Shorland, 1 9 9 8 ) . The key process

marked exacerb ation, it was decided that a short reg­

is that the patient overcomes their rear (ror example

ular walk of good quality would be of greater benefit.

of a spider or or a particular movement) by gradually

La ra's i n i tial task was to find a reason able baseli ne

approaching rather than avoid ing the cause of the fear.

starting ti me or d i stance that would not i ncur a

This can be a very slow process and the speed of expo­

massive Oare up and which was m a nageable even on

sure is determi ned by the patient rather than by thera­

bad days.

pist bu llying! A successful outcome is achieved when the process is graduated (slowly more and more dimcult levels are mastered), repeated regularly and prolonged.

Management stage 2

Gradually, tbe patient gains confidence and learns that

Lara returned 2 weeks l ater. I saw her hoVice over 2 days,

their fears are unfounded as they achieve their goals.

w i th each session being 1 . 5 hours.

The key to success is starting the chosen movement or activity at a realistic and achievable baseline.

She rel t she had begun to maste r lumbar move­ ments in lyi n g (e.g. Oexion using pelvic rocking and

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single leg flexing) and paced up her numbers from a n

thrown in from me, she came up with the notion of

i n itial baseline of 1 0 slow, relaxed, small-range repe­

doing it while lying in the flexed pelvic rocking posi­

titions to 1 5 fuller range and sligh tly faster repetitions.

tion. The result of this is that it helped her to find a

She had managed to generalize this out to modest flex­

way of doing the exercise much more comfortably,

i n g in sitting and was feeling good about it because

but it also introduced the idea of being ' allowed' to

she was needing quite a bit less help with dressing

play around with or modify an exercise to make it

from her husband. She made a spontaneous comment:

more acceptable. For so long patients h ave been fear­

'The most profound thing that has happened is the

fu l of doing a n exercise 'wrong ' . In my opinion . this is

sense of relief. I believe what you say; it makes sense.

very unhelpful when dealing with this type of patient

It gives me control and it allows me to have a vision of

and problem.

my life with some kind of fu ture. Whatever it is going to be it will be better than where I have been for so long-I know that . ' S h e had had o n e bout of a very bad flare u p for 1 day but had managed to keep most of the programme going. For the first time. the flare up had not unduly

Some new exercises were added: • sit-up i n supported (pillows behind back) slouch

Sitting • lumbar extension i n lean fo rward sitting with arms

supported on knees.

bothered her. Her comment was, 'It taught me that

The first was decided on after experimen ting in differ­

my desire to progress quickly may be my worst enemy.

ent starting pOSitions to get some dynamic abdominal

The day before I got carried away with the exercises

work going and to encourage active lumbar flexion.

and paid for it. The good thing was that I recovered and

Lying l1exion from the 'top-end' was found too d iffi­

haven't lost any ground.'

cult. Bilateral leg lifting from the crook-ly ing position

She found the use of regular short resting far more

produced s harp pain in the initiation phase of the

effective than responding with rest only when pain

movement, but reaching forward from a gentle slouch

became severe and unmanageable.

sitting pOSition was enjoyable! This was because, first,

The second half of the first session was spent going

she found it rewarding to try slouchi ng after so long

through some of the things looked at in the in itial

avoiding it and, secondly. the movement was pain -free

physical examination. Movements and the exercises

and easy to perform. Lara could immediately see how

she was doing were observed and discussed, a n d

her abdominal muscles were working quite strongly.

walking, climbing steps, balance e t c . were reviewed.

that she was flexing her back, and that she could

The focus was on patient comments about the quality

occasionally try a lying, or half lying, sit-up when ready

and feel of each task/movement, not o n pain and not

to progress.

o n any ' therapist opinion' about the movement

Sitting with arms supported on knees was the

( u nless helpfu l ) . At appropriate times, positive rein­

star ting position fou nd most useful as a progression

forcement was given. DiffIculties were discussed and

from extension in the crook lying position. It should

Lara was encouraged to problem solve and find out

be remembered that Lara ' h ated ' extension from the

for herself rather t ha n be told or shown alternatives

standing position.

by me. For example, she had found left SLR in crook lying difficult and uncomfortable to do. She had kept to a baseline of four repetitions three times per day but had not progressed it and did not like doing it much as she immediately felt sore in her leg and back. I explained that the exercise strengthens weak hip

and back muscles, as well as moving a nd stretching leg muscles and nerves from the back. Also, that sub­ tle adjustments of the back, the leg or the starting position were often helpful in making movement eas­

Education 2 In the second half of the session, time was taken to explain the importance of setting realistic goals in all areas of Lara's life and looking at the physical compon­ ents that needed to be mastered in order to achieve these goals. The following goals were chosen and pro­ grammes worked out to help to achieve them:

ier. I gave an example of doing the exercise in a semi­

• dreSSing independen tly

reclined position. She tried it and was not convinced.

• getting on all fours

She then tried it sitting but fou nd this even harder.

• swimming one length of the pool

After 5 minutes or so experi menting, with some ideas

• starting hobbies again (e.g. 110wer arran ging) .

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The health re q u i rements of tissues

progressing the swimming and could now manage

Some si m ple informati on was required about the needs of' musculoskeletal and neural tissue for move­ ment and exercise to remain healthy and to improve fitness. Part of this included the notion that fitter tis­ s u es wh ich are used in a confid ent way have a b etter chance of becoming less sensitive. Key aspects of tissue req u i rements includ e th e need for regular through­ range movements. comfortable stretching. progr essive strengthening. endurance training. and im proved coord ination. A handout was gi ven to Lara .

two lengths of the swimming pool wit hout a signill­ cant O a r e-up. She had star ted som e simple gard ening tasks as well as getting more i nvolved in some or her hobbi es. M ovement


a nd




improved. For exam ple. she was able to get onto the Ooor and as a result now managed to get in a nd out or the bath. She was manag i ng a few haJ f sit-up exer­ cises a nd had increa sed her d a i ly walking to a com­ fortable 20 mi nutes. She had progr essed to d oi ng a full SLR from supine lying. Time was spent d i scussing some new goals. These

Und erstanding th e m u ltiple facto rs that can


trigger pain

enter ta i ning her family to a

meal and

the possibility of a holiday for a few days with her

Headaches were used to illustrate the multiple trigger­

husband .

ing factors that can be involved in triggering pa in.

Some current d ifficulti es were d i scussed. In particu­

Most pati ents are able to come up with some of the fol­

lar this included a ma jor concern she had abou t the

lowing factors that can trigger or worsen a heada che:

pa i n and the hypersensiti vity: 'I am d oing so much

d iet. tired ness. stress and tension. a parti cular envir­

b etter physically. I am achieving more. I continue to

onment or situati on. as well as more physical factors

improve a nd my confidence is gradually returning, but

lUee prolonged postures or overexer tion when tired or

the pa i n and symptoms seem to be much the same a nd

hungry. These issues are then d i scussed in relationship

I am stUl very tender.' This prompted a review of the

to the variability of the patient' s pain and in such


nature of chronic pain and hypersensitivity. but a lso

way that th e patient can start to und erstand the com­

a review of pain reduction a nd d esensitizing strat­

plexity of the problem and the cli ffi culties in trying to

egies that may be helpful. Some of these were the use of

relate the waxing and waning of pain to a single struc­

rest and relaxation techniques, progressi ve d esensitiz­

ture or pathology. RealiSing that multiple fa ctor s are

ing ma ssage. heat/cold, 'nice' exercises and stretches.

often i nvolved in precipitating Oare-ups helps the

'Nice' exerci ses are those exerci ses that the patient

patient to realise that there is more to pain and its

chooses which feel good and are often u sed to ease

behaviour than j ust physi cal factors.

d i scomfort: they are usually a combination of relaxed through-range exer cises a nd comfor table stretches. A simple breathing relaxation technique was ta ught

Management stage 3

and instr uction gi ven regardi ng the use and progression

On month later Lara retur ned again ror two more

of massage over the tender areas. Agai n , information

long sessions. She had achi eved all the goals and was

was written d own and hand outs gi ven.

� IJ o


The abdominal exercises you have described appear ver y general. Do you feel assessment of

• Clinician's answer

specific trunk and pelvic muscle function ( i.e.

This is a very personal ma tter, especi aUy conSidering

awareness, recruitment, strength, endurance,

the current wave of enthusiasm for speci fic muscle

etc. ) is appropriate for this sort of presentation,

control a pproaches. I would urge great caution i n over­

and if so, at what stage would you assess these

focussing on specific impairments at this stage. Muscles


work i n groups. a nd movement should normally b e for

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the most part unconscious. thoughtless and silent: this

matter and one that is really very difficult to pred ict.

is what needs to be rehabilitated. Recall that Lara had

Everyone wants their pain to go: however, the reality of

been given specific exercises for the trunl, and pelvic

long-term well-established widespread pain with its

region in relation to a diagnosis of 'instability' and had

underlying neurophysi ological representations is that.

been told never to bend without tightening her stom­

IU,e the signific ant memories of our lifetime. they are

ach. This style of approach may enhance somatic

very hard to get rid of or forget. The reality is that the

awareness as well as i ncrease fear that i.f she does not

pain wi l l probably always be there: however. many

do this she is W,ely to cause further harm. If success­

patients like Lara find that it bothers them less and it

fu l fu nctional recovery occurs then bringing more

becomes easier to manage.

focusseD 'muscle imbalance' issues in may be worth­ while later on. It is always important for a patient to feel that they have good muscu l ar control. especially around an area that has given a great deal of trouble for a long time. However. I do not thi.nk that it is desir­ able for patients to have to recruit muscles consciously before or during movements: not only is it very di.fficu l t to d o for many people. i t i s n o t natural.

Clinical reasoning commentary 'rhe application of any t herapeutic interven t ion . be it joint mobilizati o n . motor control retra ining or explanation to alter understanding. must be based on patients' un ique clinical presen talions. Recipe

What are your thoughts regarding this patient's long-term prognosis? Please include some reference to the 'positive' and 'negative' features in her presentation that you feel assist in predicting this result.

treatments or protocols are unfortunately s t i l l common in m a n u a l t herapy. a l t hough oft en the lalest 'fad' is created by those who extrapo late from thc ideas of others and n o t by the originators of the research on which i t is based. There is clearly a continuum of impairment possible within the sensory-motor system. whic b , when considered along with the multitude of biQPsychosocial fac­

Clinician's answer Lara has successful ly coped with a new perspective on her problem for over a year. She has made quite sig­ nificant gains in function and independence and has reintroduced many of her former hobbies and inter­ ests. This was a l l he lped by her open-mindedness. her readiness to accept new perspectives on her problem, and her eagerness to take responsibility for her own management. Her home situation and fi nancial secu­ rity were very helpful in that they a ll owed her to h ave time to devote to the programme. She got involved, she did the programme and she worked hard at i t . Note h e r comment above that ' worki ng w i t h chronic pain can be very hard work ' . I n this respect, it is very common for patients to make changes to t heir lives. manage well for a while, but to then relapse i n to old ways and become passive and despondent about the whole s i tuatio n . Lara is as vulnerable to relapse as aoyone and this is a strong possibil ity. Her long-term prognosis looks good. Importantly, there are two aspects to consider for the future: her dis­ ability and fu nction and her pain and symptoms. The prognosis for fu nction is good. Her recovery is already excellent and still improving; even if she relapses she knows the way out. Symptom prognosis is a differe nt

tors that influence how that impai rment will man­ ifest in


given patient. necessitates that therapists

are sufficiently open-minded and skilled in sensory­ motor retraining. While a variety of techniques are used to facil itate improved motor con t rol. it is important the underlying strategy is based on sound principles of motor control and learning theory. Again there is no recipe. Even with the growing body of resea rch to assist us i n recogniz­ ing the factors that i n n llence motor control . appli­ cation of that knowledge to our patients requires advanced assessment and teaching/training skills as well as the clinical reasoning to know which stmte­ gies are indicated and when they should be trialed. Reassessment of the effect on the differen t systems (e.g. psychological. cognitive/affect ive/behavioural. neuromusculoskeletal) should guide the progression and modil1cation of a l l interventions. Determination of prognosis may well be one of t he most diffic u l t decisions for therapists to make. However. prognosis. l ike the other categories of hypotheses. forms patterns. A t tending to the posi­ tive and negative features fr0111 the patien t ' s psy­ chosocial and physical presentat ion is the key.

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There may also be more t han one prognosis. as d is­

but. as time goes by. and particu l a rly if the prog­

cussed here. with different prognoses predicted for

nosis is not met. taking the time to relled "vhat may

the patie n t ' s functional l'ecovery and pain recovery.

h ave been missed. over- or u nder-rated i n the i n itial

The crucial factor. as with all clinical pat t erns. is

j udgment, so that future pred ictions might be

reflective reaso ning. Not simply making a prognosis

improved .

I picked Lara as a good example of the problems we

a l l can have w ith the management of chronic pain One year a fter Lara first consu lted me she was back to near normal levels of activity a nd conl1dent that she would progress fu rther. She moved in a relaxed way and was not frightened to bend her back. She could easily bend to touch the floor with both hands nat: she could walk happily on tip-toes and go up stairs two steps at a time. She sti l l had low periods and occasional pain Ilare-ups. Her pain level overa l l was. in her words. 'more manageable and less intrusive ' . She slept much better and man aged slowly to stop a l l her medication. She commented: ' Worki ng with chronic pain can be very hard work. it is a daily cha llenge that most o ften is quite conquerable, b u t on some days it is a long and very tough and tiring struggle ' . At the time o f writing, there h a d been seven visits in total and s he was coming to see me about once every 3-4 months. There had been no passive treat­ ment, but there had been a great deal of s k i lled phys­ ical appraisal and the gradual i n troduction of more and more specil'ic exercises related to more minor physical impairments. This is not always required but it had been Lara's aim to get as fit as her age and underlying condition would allow.

states. She ex hib its many features that can b e made to I1t various models a n d explanations, yet if her prob­ lem is really scrutinized there is a great deal that does not I1t. can be viewed as odd or can be u n productively classified in some way as ' n o n-organic'. She had been through a large number of therapies and consultants i n search of a n a nswer to her problem with little suc­ cess. She has been through periods of great hope with some of them, yet her hopes d windled to despair as treatment after treatment failed and consultant a fter consultant provided inadequate or even d ismiss ive explanations and attitudes to her and her problem. LU(e many chronic pain sufferers, Lara had wide­ spread symptoms and signs that do not I1t into neat diagnostic categories or syndrome presentations. She had many maladaptive movement and behaviour pat­ terns, and she had many unhelpful and u nrealistic beliefs and attributions about the n ature of her problem and the means of recovery. Her case history illustrates how an enclosed tissue-based and predOminantly pas­ sive approach to treatment really did not help, and how a multidimensional and multilevel perspective and approach enabled her to recover and lead a far fuller and more confident life .

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A chronic case of mechanic's elbow Toby Hall and Brian Mulligan


Howard is

normally healthy 51-year-old male who

c o r t isone injections i n the region of the right lateral

ha s a sed en tary l ifestyl e . He is right hand d omi na n t and

epicondy l e near the common extensor origin . This had


enjoyed the occasional game of Imvn bowls prior to the

no e ffect in red u c i n g the s y mpt o ms and o n l y i n creased

onset or his elbow p ro b l e m. He runs a smal l motor vehi­

his p a i n lor 48 ho urs after each injectio n.


repair shop

attached to


se rv i ce station. He usually

manages the business. but for 2 weeks be had to stand in

lor one of his mechanics who was

aw a y

on sick leave.

The principal natme o f the reliel' work invol ved fit­

Chronic stage At this s tage, Howard was having proble ms writing

ting new exhaust sys tems . The majority of tasks were

and using

undertal,en in a vehicle ins pection pit with the car over­

doctor to a rheumatologist, who ordered a bone scan.

head. Howar d noticed the sudden onset of right elbow

The results o f the scan were normal, w i t h an app ar­


computer at work He was re ferred by his .

pain at the beginning of the second week of rel ief work.

ent coincidental finding of i ncreased tra cer uptake in

On this particular day, he experienced extraordinar y dif­

the C5-C6 and 1'3-T4 facet

lkulty loosening

patient was then advised to see a phy siothera pist fo r


corroded nut using a socket wrench,

with considerable force being required. Within an hom, he became

aware of moderate lateral elbow p ain with

any forcel'ul

j O in ts b i l a terally. The

s treng thening and s tretching exerc ises. There was no previous history of arm problems des p i te the fact that Howard had been a motor

the rest of the week as h e was unab le to restrict his activ­

mech a n i c for 15 years of his \Norking life. However.

ity because there was no replacement. The pain gradu­

th ere was a h istory of recur rent neck p a i n for which

ally increased to the point of becoming quite severe. In th e following week, be returned to his normal duties, which mainly involved supervising mechanical

he h a d never s o u g ht trea tment. These ep isodes were c aused by lo n g periods working u nderne a t h ve hic l e s


the last being 3 years ago.

wo rk and office duties. The pain continued to bother

At initial ev al uati on 4 months a fter the o n set of

him constantly but had subsided to a moderate inten­

symptoms, the p a tient complained of pai n in the

sity. Being a busy person, he let the situation continue

a nterol a teral and posterolateral aspects of t he elbow

lor a

further 2 weeks . He then went to see his general

medical practitioner, who prescribed non-s teroi dal anti-inflammatory d rug s for 4 wee ks

6.1). There was no pain or o ther symptoms else­

Duri n g this

There was no apparent stress in Howard's life and he

constant to

was coping well "\lith his problem . He h a d continued to

intermittent nature. The doctor the n , over a period

work a n d on questioning there were no work or f a mil y

period, the pain began to change from an

(Fi g.

where in the left or right upper quarter.



of 8 weeks, administered a series o f th ree local

issues that might have interfered with his recovery.

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� I Jo

Body chart indicating the extent of elbow pain.


How did you interpret the effects of the

change. Cortisone is a po w e rfu l anti-inflammatory

medical interventions on the patient's

agent: if there was any remaining inflammation


some relief of sympto ms would likely have resulted. It has been demonstrated that in chronic tennis

• Clinicians'

elbow (also known as lateral epicondylitis or lateral

answe r

The patient report ed

epicond ylal g ia) there is histological evidence of angio­

gradual change in the nature of

fibroblastic hyperplasia (Nirsc h I and Petrone, 1979)

his symptoms during the 4-week period when he was

and mesenchymal transformation ,vithin the common

taking non-steroidal anti-inflammatory medication.

extensor tendon at its pOin t of insertion into the lateral


Sarkar, 1980). In contrast ,

He felt that his sym ptoms changed from b ein g con­

epicond yle (Uhthoff

stant to intermittent. This improvemen t may have been

there is no evidence of acute or chronic inflammator y

related to spon t aneous recovery of the disorder rather

cells. Prolonged anti-inflammatory m edication or


than the prescribed medication, especially as he had

cortisone injection are, therefore, unwarranted in the

stopped the activity that had caused the symptoms

management of chronic tennis elbow and were (as

in the first place. There may have been an inflamma­

would be expected) u ns u cce ss ful in this case.

tory element to the co n dit i o n , arising from repetitive micro trauma through ove r use and the sudden exer­ tion (overload) required to loosen the corroded nut. This inflammatory component subsided with time and with the aid of the anti-inflammatory medication. The symptoms rem a ining after the 4-week period were pro b abl y related to mechanical dys func t ion of


What were your initial thoughts and hypotheses about the possible source ( s ) of the patient's elbow pain!

• Clinicians' answe r

the elbow complex. The patient reported a temporar y

In this case of localized pain in the region of the lateral

increase in pai n after local cortisone injections in

epicondyle, possible structures/pain sources to be con­

the region of the lateral epicondyle, but no overall

sidered include local joints, musculotendinous elements

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and neural tissue, as well as remote structures, par­

or inl1ammatory cells in chronic tennis elbow (Nirschl

ticularly within the lower cervical spine, Working

and Petrone, 1979; Uhthoff and Sarkar, 1980) and

hypotheses in order of priority were:

the patient's poor response to powerful local anti­

1. The insertion of the wrist and Unger extensors

at the lateral epicondyle, notably extensor carpi

radialis brevis 2, The nervi nervorum supplying the radial nerve or







inllammatory agents, it would appear that inflamma­ tory nociceptive pain is an unlikely explanation for the ongoing symptoms. The pathobiology of tennis elbow has been pro­ posed to involve a tear of the tendon of origin of the extensor muscles from the lateral epicondyle (Cyriax,

1936: Nirschl and Petrone, 1979). The tear occurs at

3, The lower cervical spi n e (C5-C7)

the junction between muscle and bone, and healing is

4. The radiohumeral and radioulnar joints.

slow because of a lack of periosteal tissue overlying

The evidence in support of local structures includes a

this bone area (Putnam and Cohen. 1999). It has been

well-defined area of pain , without evidence of associ­

shown that the granulofibroblastic material laid down

ated proximal or distal symptoms; a history of abuse of

in the repair process contains free nerve endings

local elbow structures immediately preceding the onset

(Goldie, 1964). Repetitive microtrauma from overuse

of symptoms: activity involving local structures repro­

or abnormal joint biomechanics may overload the

duced the symptoms immediately after the symptom

repairing tissue, mechanically distort the scar tissue

onset: and an unvarying area of symptoms over the

and thus stimulate the in situ free nerve endings

history of the condition. In support of contractile and

sulTiciently to evoke mechanical nociceptive pajn.

associated elements as the most likely pain source is the

ChroniCity of the problem may be related to continued

history of excessive muscle force required to release a

use of the arm. causing repeated microtrauma to

corroded nut. The evidence against local structures

the scar tissue. which has not yet gained adequate

includes tbe failure of local cortisone injections to relieve pain. although it is highly likely that this relates to the lack of an inflammatory process rather than

strength to withstand normal function. In the case

injecting the wrong tissue.

tendinous overload , either by repetitive microtrauma

history, there is some evidence to support this hypoth­ esis, The history of onset is consistent with musculo­

At this point there is little evidence to support

or sudden strain. The pain has changed from a con­

remote slructures as a source of pain, other than a

stant to intermittent nature and is related to activities

tenuous link with the bone scan abnormalities at

(such as keyboarding and writing) that involve repeti­

C5-C6 and T3-T4, as well as a history of stressful

tive use of the proposed damaged musculotendinous

cervical spine postures working underneath cars.


Furthermore, there is no complaint of neck symp­

Alter natively, it has been suggested that ischaemia

toms to suggest somatic referred pain from cer vical or

plays a part in the pain process (Putnam and Cohen,

thoracic structures, nor dysaesthesia or sensory loss

1999). The blood supply to the muscle origin is

to support cervical neural compromise.

limited and it is suspected that it would be prone to reduced flow after injury (Uhthoff and Sarkar, 1980). Ischaemia can cause nerve endings to lower their

What were you r hypotheses regard i n g the

thresholds for firing (Gifford and Butler, 1997). The

pathobiological pai n mechanisms involved?

nerve endings may then nre more readily and with

What evidence was there to support (and


negate) your hypothes is?

• C l i n i c i ans'


t normally painful. The patient's age

is a Significant factor in reduced vascularity of the musculotendinous insertion .

answe r

At this point in the examination, there is little

In this case, the condition is certainly chronk. being

evidence to support a neuropathic disorder involving

now 4 months in duration. If we assume that the ori­

abnormal nerve conduction, central nervous system

ginallissue damage was a tear of the musculotendi­

changes or maladaptive behaviours. Certainly, there

nous insertion related to forcing the corroded nut,

do not appear to be any significant psychological or

then this soft tissue damage should normally have

social issues that could contribute to a central pain

repaired by this time. C onsiderin g the lack of evidence


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• I

• C linical reasoning commentary

attended to carefully. as have 'missing features'

The response to Question 1 nicely demonstrates

features that would be expected





how hypotheses relating to pathobiological mecha­

clinical disorder. such as the absence of neck symp­

nisms (notably tissue-healing mechanisms) have

toms with the hypothesis of somatic referred pain

been ge nerated early in the clinical encounter and

from cervical or t hora cic structures. Whereas the

that tentative decisions are being formed at the out­

novice clinician often ignores features that do not lit

set. rather than at the end. of th e examination. It

with the favoured hypothesis. the expert clinician

is also evident that. the integration of propositional

avoids this error and weighs bot.h the supporting

knowledge of pathobiological mechanisms within

and negating evidence

the broader knowledge base of the expert clinician


These two hypothesis categories are not each

e n abl es the consideration of this patient's clinical

considered in is olati on

presentation in

intricately intertwined. and consequ.ently have an

the light



but rather are found to be

impact on the deciSion-making process proceeding


A Dumber of hy potheses relating to the struc­ tural s o ur ce s of the elbow p ain and related

pat hobi­

in relation to the other h y pothe si s category. This is rel1ective of


richly organized knowledge base that

ological mechanisms (both tissue healing and pain)

is deep as well

have been generated from this patient's history thus

clinical reasoning of the


with ranking of

these hypotheses evident.


bro a d. and is characteristic of the

expert clinician.

fn addition. there is evidence of attention to the

Testing of these hypotheses is apparent in that con­

possibility of psychosocial factors (yellow. blue and

sideration has been given to the supporting features

black flags: see Ch.

in the patient's presentation. [mportantly. however.

contributecl to the patient's p a i n state and created

non-supporting clinical nndings have also been

obstacles to his recovery.

Pain behaviour

I). which potentially could have

llexed as he did using


writing pen in the


principal aggravating activities were writing for more than 10 minutes and use of a co mp u ter keyboard for more than 15 minutes. The pai n never


stopped him undertaking the activity. but at the end

if he slept with his elbow llexed

of a busy day involving these activities. his elbow pain

tucked under the pillow. In the morning he generally

would not settle until the fol l owing day. Gripping

awoke pain-free and without elbow stiffness. unless

and squeezing activities (including carrying heav y

he had been sleeping with his arm in an awkward


objects in the right han d ) were

also painful. For this

Howard was un a w a r e of any position or activity that wou Id ease his pa in. His sleep was on ly disturbed

and the forearm

pOSition during the night. Specific questions regard­

and sustained

reason he had stopped playing social lawn bowls

ing the effect of cer vical movements

for the duration of his symptoms. He also described

cervical postures p rovide d no further information.

occasional pain when bru shing his teeth or shaving.

Specific questioning regarding general health. pre­

as he had the same difficulty holding and manipulat­

vious medical history and other related health issues.

ing a toothbrush/disposable razor with the elbow

revealed nothing apart from dermatitis.

rt1 D


Did you specifica l ly screen fo r o r appraise the patient's psychos ocial status (i ncluding h i s

u n d e rsta nding of the probl em and his feelings

• Clinician s'


In response to the question of what was his main

p atient answered that it was pain in the

abou t his management to date and the effect it

problem. the

is hav i ng o n his life)? Did th is factor have an

region of the lateral epicondyle when writing or

effect on his symptoms?

using the computer keyboard. The patient had never

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before been to a physiotherapist for treatment. His

burdened by his elbow disabil i ty He believed that auto­

only reason for attendin g was because he had been

mechanics had to put up with some impairment dur­

asked to do so by his treating d octor. His un derstand­

ing their working life as a consequence of the physical


ing of the problem was ba sed on what he had been

nature of their work. His previous hist ory of neck pain

told by the doctors he had consu lted in that he had

bore witness to this fact.


Howard appeared q uietly resig n ed to his lot. He felt

tendinitis of the wrist and fmger extensors. The elbow p roblem certain ly affected his life. He

that medical management had not really h e l ped him

had pain through the day at work and was unable to

and that he was p robab l y going to have to live with

perform his normal duties of writing and computer

a painful elbow lor a considerable length of time.

keyboard operation without significant exacerbation.

Becau s e he was m anag ing the business. he also felt

Being in a ma na gerial position. he felt he could not

fru strated that he was unable to take time off when he

reduce his work activity by taking sick leave. In add­

first hurt his e lbow. He bel ieved that the pr oblem

ition. his soc i al life had been disr upted as he had been

would have settled if he had been allowed to rest

forc ed to stop playin g recreational bowls. Even t h oug h

initially and that he would not have been in the

the elbow problem was a sign iflcant intTusion in his life

present situation if his mecbanic had not been


Howard still felt able to cope and was n ot pa rticularly


off work.


On physical examination. Howard had poor sit ting

more restricted tban flexion. Positioning the spine in

posture. with an in creased thoracic kyphosis. pro­

combinations of extension with ri g ht side flexion and

tracted and depressed shoulder girdl e bilaterally and

right rotation. in addition to flexion with left side

an incr e a sed cervical spine lordosis. In the standing

flexion and left rotation. was p a in free although the

position. the upper limb s were held in inter n al rota­

moveme n ts were l imited in range.



tion at the shoulder. both elbows were maintained in

Right and left s boulder mobilit y spec ifically abduc­

slight flexion and both forearms were pronated. There

tion and hand behind b ack w as mildl y restricted by



soft tissu e

sti f fness. The addition of neu ral tissue-sensitizing

swelling or any other sign of de for mity in the elbow

manoeuvres sligbtly decreased the abduction and




evidence of



hand-behind-back ra n ges of motion on bot h sides


equ al ly None of the se manoeuvres provoked the .

patient's symptoms. nor any disco mfo r t in the lateral

Active movements

elbow region. However. wrist extension in combin­

Right elbow and wrist mobili ty was full and without

ation witb finger and full right elbow extension evoked

pain. C er v ical range of motion was limited in a l l direc­

the patient s elbow pain with tbe right shou l d er in

tions by stiffness. Rotation and side flexion was more

either abduction or flexion. These same movements on the left side were completely painless.

restricted to the left than the right. and extens ion was




What was your interpretation of the postural observations? Specifically. what hypotheses did you consider and how did you plan to test these?

s tra ted abnormal postu ral features related to speciftc

pain sy nd romes such as cervical beadache (Haugbie et al.. 1995; Wat son and Trott. 1993). but other

• Clinicians' answer

investigations have found no such link (Refshauge

Abnormal posture is a frequent finding during rou­

a com m o n form of spinal and upper limb postural

tine clinical examination. S o me studies have demon-

abnor m ali ty

et al.. 1995). This particular pati en t presented with

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has been prop osed




Burfield, 1998) that forearm muscle imbalance and

extensors. In contrast. shoulder lIexion is usually less

abnormal radiohumeral alignment plays a significant

provocative than abduction to upper quarter neural

role in the prolongation of tennis elbow. Similarly,

tissue. Hence. there should be a greater pain response

White and Sahrmann (1994) contended that abnor­

to wrist extension with the arm in abduclion rather

mal posture and related muscle function may lead to

than l1exion. if the upper quarter neural tissue is sen­

repetitive microtrauma , which may be a factor in the

sitized. If the source of the symptoms is the extensor

development and maintenance of pain syndromes.

muscle origin (or structures other than neural tissue),

The therapist must, therefore, determine whether the

then wrist extension should be equally symptomatic in

patient's posture has any bearing on the development

shoulder abduction and shoulder nexion, as was found

or maintenance of the presenting condition.

in this case.

In this case, the postural assessment revealed no significant difference between the left and right upper limb , which may indicate that the variance in posture was not directly related to the pain disorder. However, the abnormal posture and possible related muscle dysfunction may have been a contributing factor to the problem. Lee (1986) has postulated that the type of head and neck posture seen in this patient may be a

precipitating factor in the development of chronic

tennis elbow. and that correction of this posture is an important aspect of treatment. The history of neck problems, abnormal bone scan findings in the lower cervical and thoracic spine. and the abnormal cervi­ cal and thoracic posture indicate the need to examine the cervical spine thoroughly. If the cervical spine was found to be a significant contributing factor to the problem. then the abnormal posture may need to be addressed. In addition, the flexed and pronated forearm posture may have been caused by muscle imbalance or joint restriction in the elbow complex, necessitating assessment of both muscle and articu­ lar function.



At this stage, were there any potential contributing factors (e.g. environmental. biomechanical) identified in either the subjective or physical examination that you considered may be relevant to the development or maintenance of his problem?

• Clinicians' answer Tennis elbow is not restricted to those that play tennis and other racquet sports (Kivi. 1982). It is common in the general non-sporting popUlation, especially amongst those whose occupations involve repetitive or forceful forearm, wrist and hand activities (Plancher et al.. 1996). particularly involving overuse of gripping and wrist extension. Following an extensive survey of 15000 residents of Stockholm. Allander (1974) reported an annual incidence rate for lateral epi­ condylitis of 0.1- H{, and a prevalence rate of 1-10'1'0. A number of factors can be identified from the subjective examination that may have contributed

What was your interpretation of the pain provoked by wrist extension and shoulder

to either the onset or the maintenance of Howard's lateral elbow pain: • a sedentary lifestyle. including working in an


office. that suddenly changed to a physically demanding job involving repetitive and forceful

• Clinicians' answer

wrist and arm activities. with the neck and arm in

Clinical experience suggests that peripheral nerve

awkward positions: although he had the skills

trunk sensitization frequently accompanies lateral

required to perform this job. he did not have the

elbow pain , with this finding also reported in the

necessary musculoskeletal conditioning

literature (Yaxley and Jul!, 1993). To determine the

• continuing to work as a mechanic for some time

presence of nerve trunk sensitization. an assessment

after the incident of loosening the corroded nut

for active movement dysfunction is needed (Hall and

would have amplified the problem

Elvey, 1999). The movements of wrist extension and

• activities (e.g. typing and writing) after returning

shoulder abduction are provocative to upper quarter

to normal duties may have delayed normal healing

neural tissue (Elvey, 1979; Kleinrensink et al.. 1995: Lewis et al .. 1998: Reid, 1987). Active wrist exten­ sion will also stress the origin of the wrist and finger

through repetitive overload stress • age







reported slower healing times for older patients.

Copyrighted Material


sometimes be

Signifi can t factor in tennis elbow

In terms of the physical examination. the foll owing


factors may have contribu ted to the onset or mainte­

(Gunn and Milbrandt. 1976: Lee. 1986).


nance of Howard's lateral elbow pain: • overactiv ity of the elbow t1exor and forearm prona


tor muscles may ind ica te abnormal funct i o ning of the upper limb muscles • active movement dysfunction of the cervical spine. Even t h o ugh the pati e n t demonstrated full range of

elbow and w rist motion. the resting posture suggests overactivity of the elbow t1exor and forearm pronator

muscles. This may be an in di cation of abnormal functioning of the upper limb muscles. A muscle imbalance may cause abnormal joint axes of rotation

and repetitive microtrauma from ever yday joint movement (White and Sahrm ann 1994). Mack and .







between th e forearm supinator and pronator muscles

is a causative factor in tennis elbow. PhYSical examination of the cervical spine revealed evidence of active move ment dy sfunct ion altho ugh .







increased tracer u ptake in the C5-C6 facet jOints bilat­ erally. Some authors have pro posed that clinical and subclinical neuropathic disorders of the cervical spine

• Clinical

reasoning commentary

Although observation is just one small part of the physical examination in this ca se it is interesting to .

note how the ilndings from this common 'test' can be used to form and test hypotheses in severa] cate­ gories. Tbe I1 n dings have informed decision making related to the physical impairments (e.g. j O i n t restriction in the elbow) and sources of the elbow pain (e.g. cervical spine). factors contributing to t.he pr o blem (e.g. abnormal posture). and ma nagem en t and treatment (e.g. postural correction). as well as directing later search strategies. such as the need to examine the cervical spine. Tbis illustrates the abil i ty of the expert to recognize the relevance anel meaning of clinical features. and the asso ciated implications [or subsequ en t actions. In addition to improving the accuracy of decision making. this also enhances the effkiency of the overall clinica l reasoning proce ss Extensive clinical experience, and relle c tion about such experience. is integral to developing this ability .


Muscle tests

Passive movements

Signillcant pain was reproduced on palp at ing the ori­

Mild p ain was reproduced and abnormal s ti ffness

gin of the right extensor carpi radialis brevis muscle

detected on passive accessory motion testing of t h e

on the anteroinferior aspect of the lateral epicondyle.

right radiohumeral jOint but not the humeroulnar

as well as th e proximal muscle mass of the w rist and

jOint. nor tbe joints of the left elbow complex Pain

finger extensors. Gripping with mi l d pressure repro­

and stiffness was more apparent with the right elbow

duced the pain with the elbow flexed or extended. but

in full extension and pronation. Neural tis s u e provo­


only in forearm pronation. Isometric contraction of

cation tests biased to the radia l and median nerve

the wrist and finger extensors also reproduced t h e

tr unks did not reproduce the sy mptoms

elbow pain. Isolated isometric contraction of the mid­

range of movement was equal between sides. Normal

dle finger extensors was notably more painful. but

responses were elicited on p al p ation of the nerve


and the

testing of the lorearm supinators was symptom free.

trunks in th e upper limb. Passive physiological motion

Stretching the wrist into flexion was provocative. par­

testing of the cervical and thoracic spine revealed

ticularly with the forearm pronat ed and the elbow

marked restriction of movement at CS-C6. C6-C7

fully extended. Muscle l ength of the forearm supin­

and from T3 to T6. Passive accessory motion testing

ators and pronators was assessed indirectly by observing

indicated a pain and stiffness relationship at the same

the range of active m ove ment of forearm pronation

spinal levels. It was no t possible to r eproduce the

and supination and found to be normal. Further

arm sy mptoms using any provocative manoeuvres of

assessmen t for muscle imbalance was left for a later

the cervical spine.

session (if necessary) because the principal goal of the initial assessment was pain relier.



Copyrighted Material



(MWMs) (Mulligan




1999) of the elbow was also


assessed . Th is was co ns i de red wor thwh i l e as t hey often have the elTect of i n c re a s i n g fu nction wh i l e a t the s a me t i m e red u c ing p(] i n . an d do not us u a l ly req u i re a r e duc t i on i n du ties at h o me or work . MWMs are sustained mob i l i z a tions ( accesso ry gl id es ) of a j oi n t Si mu l tan eo us ly

a pplied


the partic u l a r

move ment t h a t i s pa in fu l or res tricted i n r a n g e . [ n c a se s o f so ft t i s s u e l e s i o n s ( s u c h as te n n i s e l b ow ) . the gl ide i s acco m pa n i ed by contra ct i o n o f the muscles s u r ro u nd i ng the

j o i n t . The m o s t i mp o r t a n t p ri n ci p l e

to fo llow i n us i n g MWMs is that the p a i n associated with

the m u scl e c o n traction o r j o i n t move ment

should be co mpletel y relieved by t h e mob i l izatio n . In some i n s t a nc e s . pai n may not be relieved at the

F i g. 6 . 2

Late ral g l i d e of t h e e l b ow.

fi rs t attempt a n d the t hera p i s t must adj u s t eith e r t h e force of t h e gl i d e or t h e p l ane in w h i ch i t i s made. F u r t h e rmore . the gl ide should be a p pl i e d as close as

border of the h u m er us . as c lose as poss i b l e to the

po ssi ble to the j o i n t l i ne . If p a i n i s no t a l l e v i ated. even

el b ow j o i n t l ine ( F i g .

after adj ustments are made by the thera p is t . then


6 . 2 ) . T he other h a n d was pl ac ed

j ust d is tal to the j oi nt l i ne on the med i a l border of t h e

tec h n iq u e i s not i n d icated and shou ld not be used . In

u l n a a n d mobi l iz ed i n a late ra l d irec t i o n . The gl ide

c a ses o f c h ronic ten n i s elbow. the passive a ccess ory

was sustai ned w h i le the pa tie n t p er lo rmed

moveme n t that u su a l ly r e l ieves p a i n is

that n o rma l l y reprod u ce d h i s symptoms ma r ked ly.


la tera l g l id e


a c t i vity

of the u l n a a nd rad i u s on the h u m e r u s (Mu l l i ga n .

G r i p p i n g was chosen as i t was I'u nctio n a l

1 999).

be e a s y for t h e p a tient t o perk) [ [n a t h o m e a t

To deter m i n e whe ther the t e ch n i q ue was i ndicated a l atera l gJ i de was

tria led . The prox i m a l aspect of the

e l bow w a s s t a b i l ized w i t h one h and over the la tera l

wo u l d



l a ter

s t age i f necessa ry. It was lo u n d t h a t t h e pain n o rm al l y

ca used by gripping was not prese n t d u r i n g t h e


ca tio n of th e l atera l g l i d e .



What was yo u r wo rking hypoth e s i s at the c o n c l u s i o n of t h e phys i c a l exa m i nati o n ? What c l i n i c a l fi n d i ngs te n d e d to s u p p o r t or d i s c o u n t yo u r th i n k i ng!

F i n d ings in sup po r t of l o c a l s tr u c t u re s a s

a so urce

of pai n i ncl u d e : • s y mp tom reproduction


a c t i ve wrist extension

was u nc h a nged with e i t h e r

shoulder flex ion or

e lbow Ilex i o n

• C l i n icians' an swe r

• symptom re prod uc t i on o n m i l d ly fo rceful g r i p p i n g

The p hysic a l exa m i n ation fi nd i n gs correlated we l l

• sym p tom reprod ucti o n o n isometric contraction o f

with t h e s u bj ecti ve com p la i n t a nd s ugges t ed a dis ­ order cha racteri s t ic of l atera l epicondy l i t i s . There was

the wrist and fi n ge r exten so r s . a n d i n pa r ti c u l a r t h e m i d d le fi nger ex ten so rs . wh ich a r e t h ou g h t to

s tron g evid ence of l oc a l structures as th e source of

i nd i c a t e involveme n t of e x tensor carpi rad i a l is

the sym ptoms . n amely extensor c a rpi r a d i a l i s brevis a nd the rad i o h u mera l j O int. There was l esser ev i de nce for refer re d p a i n

(rom remote sources . [t was pro b a b le

brevis ( Wad swo r t h . • pain on s tretc h i n g

1 9 8 7) the f mger extensors

• symp tom reprod uctio n on pa l pat i on of the l a teral

t h a t t he cerv i c a l and t h o racic s i g n s were related to a

epicond yle at the s i te o f th e origin of the extensor

c o i n cide n t a l degen e ra tive disorder a nd the re was no

c a r p i radi a l is bre v i s m uscle ( Noteboom et a l . .

ev ide nce o f n e u r a l tissue i nvolveme n t .

• n o p a i n o n g rippi ng wit h the M W M .

Copyrighted Material

1 9 94)



sy mptoms . by way of axonal compro­

S o me w h a t i ncon sistent wit h t h is hy pothesis ( b u t n o t


u n commo n ) w a s the fi nd i ng o f p a i n o n gri p p i n g w i t h

mise or dysaesthesia , t hen app lying

t h e e l bow ei t h e r l'lexed o r ex tended . The find i n g o f

movements to c l ose the ri ght lower cer v ical i n ter v er te ­

rad iohu me r a l j oi n t dysfu n ction o n p as s i v e accessory m o tio n tes t i n g was a lso i nconsistent with a tend i n o ­

rig h t rotati o n ) should be provoc a tive . Aga i n . t h i s was

Find ings i n s uppor t o f remote s tr uc t u res a s a

movement dysfunc­ c l i n i c a l pattern consistent

• c e r v i c a l a c t ive a n d c o m b i n e d

• bone


sca n



a b n o r m a l i t y a t C S -C fl ,

c o n s i s t e n t w i t h the



c erv ic a l l e vel


• c e r v ic a l p a s s i ve phys i o l og ic a l move m e n t d y s fu n c­ t i o n in a reg i o n the



com b i na ti o n or

fora men ( exten sion w ith r i gh t s i d e l1ex ion a n d

was consistent wi th ne u ra l tissue sen s i tizatio n (le ft side f1ex i o n ) , b u t fur t h er testi ng n egated th i s poss i b i l i t y,

sou rce of p a i n i n c l u d e :

with th e

b r al


not th e ca se. Cervic a l active movement limitation

p a t hy as the so u r ce o f pai n .

t i o n , a l t h o u g b not i n


(C )-C fl , Cfl-C 7 ) c o n s istent w i th

s y m p toms

• the pain and s ti ffness relati o n s h i p fou n d o n pa s s ive ac cessory motion testi ng in


re g io n

(C5-C 6 ,

Tend i ng to negate the cervi c al spine as a source of the pa i n was the i n a b i lity to re prod u ce a ny a nn symp­ toms using a range of p rovoc a t ive manoeuvre s . There was a lso no evidence of a neurogen ic disorder. N e u r a l

tissue provocation tests. outlined by H a l l and Elvey ( 1 9 9 9 ) , fa i l e d to re vea l a ny S i g n i fi c a n t a b n orma l i t y. A neurological examination was n o t

u nder t ake n as i t

is u nlike ly t o b e sul"ficien tly se n siti ve t o detect the m i ld signs of neural co mprom ise that m ay be presen t i n ten nis elbow ( G un n and Milbrand t. 1 9 7 6 :

Lee. 1 9 8 6 ) .

C6-e 7 ) co ns is te n t w i t h the a r m sy m p to m s . Assessmen t of cer vi c a l act ive movements r e ve a l ed

• C l i n i cal

reasoni ng commentary

l imi tation of movement witho u t p a i n . C l i n ical p a ttern

Th i nki n g rela ted to the recogni tion of c l i n i ca l

recog n i t i o n fo r arm p a i n , be i t a mechan ica l n ocice p­

patte r n s i s evident in this response. Pattern recog­

tive or neuropathic d i sor de r. is dependen t in p a r t on


k ey act ive and c o m b i ned movemen t

combin ations, Clin ical pa ttern s can be recogn iz e d fo r ce r v i c a l neural

matically used by expe r t cl inicians , is an emc ient

tissue sensitization, ce r v ic a l neu r a l ti ssue axo n a l

c l in ical data and making appropriate clin ical deci­



h a l lm a rk o f t he clinical reaso n i n g auto­

a cc u r

a te process for handling large amounts of

com prom i se/dys aesthesia , a nd cer v ic a l somatic tissue

sions. Nevertheless, these patter n s must still be

dysfunction ( d isc a nd facet j oi n t) . Com b ina tio ns of the

tested to determine whether they are correct i n

most restr i cted active movements did not provide

p ar ti cu l a r cl inic al case,

evid en c e o r

a regul ar stre tch or comp ressive p attern

as o u tl i ned by Ed wa rd s ( 1 9 9 2 ) a n d O l iver ( 1 9 8 9 ) ,


In t his case. clinical patterns were sought, but were u n able to be verified. for cer­ v ica l neural ti ssue sensitization. cervical neural tis­

U rig ht - sid e d cervical somatic structures were t h e


source o f t h e e l b ow sy m ptoms , t h en a pplying i ncre as­

so ma tic tissue i mp airme n t (disc and fa cet j o i nt ) .

i ng stress in a reg u l a r, prog ressive fashion either to stre tc h or to c om press those tiss ues would h ave g iven a

and combined movements. in addition to later neural mobil ity testin g . en abled

p red ic tab l e pain provocative response. This was n o t

the reranking. if not almost rej ect ion. of these

the c a s e , If cervi c a l neural structu res were the source

bypotheses i n

axona l compromise/dysaesthesi a . and cen7ical

Testin g by way of active

p ain at a l l .


efficient and logical

m a nner.

If pain is provoked, then the patient m u s t

i n form the thera p is t i mme di ate ly to prevent ex a cer­

• Treatment

ba ti ng the cond itio n , In ad d itio n , the patient i s g iven


to u n d ers ta n d that a pos i ti o n a l faul t o f the bones

T h e tre a tme n t c h o sen consisted of an MWM to the

i n th e elbow joint c a n cause ab n orma l p u ll i n g of

elbow usi ng a later a l glide with g ri pp i n g , A thorou g h

the ex tensor muscles a t the elbow and be a co n tr i bu t­

explan a tio n

i n g fac tor to c h ro n i c ten n i s elb ow, If th is is


give n to the patient about the

the case.

pri nciples beh i n d the t ech n iq u e before mobil ization

t he n correction of the pos itio n a l fa ult by l atera l gli d ­

was co mmenc ed , It is impor t a n t t h at the pati e n t

ing o f t h e bones s h o u l d a l low g rippi n g t o become

u n ders t a n d s th a t t h e tec h n iqu e s h o u l d c a u s e no

pa i n - fre e .

Copyrighted Material


Fig. 6.4

Fig. 6.3

M o b i l i zation with move m e n t fo r te n n i s

Ta p i n g te ch n i q u e fo r te n n i s el bow.

with o u t p a i n . The strap p i n g tape had i r r i tated his

e l bow u s i n g a trea t m e n t b e l t.

skin and was removed the mor n i n g a fter the first . treatment. T he s k i n where the tape had been app l i ed

A ma n u a l therapy belt was used to m a i n t a in com­

was s l ightly red. No fu r t her strapping tape was used .

for tably s u fficient latera l g lid e force to relieve pain

On reassessment. gripping was comfortable u nt i l a

completely while the agg ravating ac tivity o f gripp i n g

modera te force was a p p l ied. whereupon pain was pro­

was u ndertake n ten t i mes i n s uccessi o n (Fig. 6 . 3 ) .

vo ked wi th the elbow in eithe r fu l l extension



A t the end o f ten repetitions. reassessme n t demon­

d eg r ees Oex i o n . Pai n o n resi s te d isometric wrist and

strated that mild gripp i n g was pain-free. Modera tely

fin ger exten s i o n . a nd local tenderness i n the reg i o n of

forcefu l g ripping and resisted finger ex te n s i o n were

the attachment o f extensor carpi rad i a l i s brev i s . was

still p a i n fu l . The s a me technique was repeated [or two

unch a n ged fro m the prev ious ex a mi n a t i o n . Pain was

more sets of ten repe titions. S ubseq u e n tly g ripp i n g

a lso elici ted on active wrist exte n s i o n with the elbow

w a s complete ly p a i n - free.

in fu l l ex tension and pronatio n a n d with the a rm

Strapping tape was appl ied to the elbow in s u c h a fas h ion as to replicate the l a teral g lid e . in an attempt to m a i n ta i n the e ffect of the tech n ique (F ig. 6 . 4 ) . The

positioned several "v ays . i n c l u d i n g by the s i de. in 9 0 d e g rees Oexion a n d i n 9 0 deg rees abductio n . Because o f the su ccess o f the i n i t ial trea tment. a

p a t i e n t was ad vised to wea r the tape for 4 8 ho urs i n

d ec i s i o n was made to i ncorporate

order t o m a i n t a i n the effect of t h e treatment. The

programme i nvolv i n g the l a tera l gJ ide tec h n ique.

need to remove the tape in the eve n t of skin irri ta tion

Howard was shown a s i m p l e mea ns o f repl icating the

wa s stressed because of t h e h istory of dermati t i s . T o determ ine t h e effic acy of the t h era py. Howard was i n s tructed to carry out his n o r m a l home and wo rk activ i t i e s , and asked to return in 2 d ay s .


s e l f- m a n agement

tec h n ique u t il izing a broad belt a ro u n d the circumfer­ ence of the body l a teral to the h u merus and j u s t prox­ i m a l to the elbow j o in t l i ne ( E-'ig. 6 . 5 ) . The patient appl ied the latera l g l i d e w i t h his l e ft h a n d . He was instructed that at no t i me s h o u l d the

• Treat m e n t

tec hnique be p ai n fu l. If p a i n occur red . t h e n the tech­


n ique was e i ther to b e a dj usted u n t i l it became p a i n ­

On retu r n i n g . the p a t i e n t reported s i g nifica n t reli e f of

free or aba ndoned. Howard w a s asked to demonstrate

symptoms after tre a t me n t . w i t h less-freq u e n t pain

the techn iq u e and g u id ance was given o n the appro­

and the abil ity to ty pe a n d write fo r longer pe r i od s

priate method . Using this appro a c h . Howard was able

Copyrighted Material


h owever n o t to the s a me deg ree as

at the in i t i a l exam­

inalio n . T h e movement of ac tive wrist exte n s i o n with the e l bow in fu l l ex tens i o n and p r o n a tion a nd with the a rm by the side. i n 9 0 deg rees l1ex i o n and in 90 d e g rees abduction, was only m i l d ly painfu l . S tretch i n g t h e extensor m u s c l e s usi ng fu ll wrist l1ex i o n w i t h a n exten ded / p ro n a ted elbow w a s n o l o n ge r pa i n fu l . In additi o n , the deg ree of sensitiv i ty o n p a l pa t i o n of the common

ex tensor






ma rkedly reduced . A decision was made to m a i n t a i n the l a teral g l i de but

ch a n ge the active component to resisted i s o metric

wrist a n d fi nger ex te n s i o n . ra ther than gripping. The p a i n - free isometric contrac t i o n was s us t a i ned for 3 seco n d s a n d repeated 1 0 t i mes i n su ccess ion . Four fu r­ ther sets were incl u ded in t h i s treatment sess i o n . The only mod i fic a t i o n to t he home

exercise was a d d i n g

end-ra nge w r i s t exte n sion to clenc h i n g o f the h a n d . Fig. 6.S

A t t h e e n d o f t h e treatment sess i o n , Howard h ad

Se lf-treatment fo r ten n i s e l bow.

p a i n-free resisted isome tric fm ger a nd wrist exte n s i o n , as well a s fu l l p a i n-free g r ip strength. It was th ought

to e l i min a te all p a i n w i th moderate gri p p i n g force. He

that a tri a l game o f lawn bowls wo u l d be appropr i a te

was advi sed to perform 10 repe t i t i o n s of the exercise

to d e te rmi ne the degree of improvement. An appoi nt­

three ti mes per day.

m e n t was arra n ged for 1 week to review prog ress .

Thera pist i n terven t i o n consi sted of a sustained lat­ eral gl ide u s i n g a belt. wh i le

the patient performed 10

repe titions of grip p i n g . Three sets were u nd er taken

• Treatme n t 4

with the elbow in fu l l extension and a fu rther three

Howard repor ted that s ince the previous treatme nt ses­

with the elbow in 90 deg rees flexion. On reassessment.

s ion there had been no d iscomfort with everyday work

gripping was no longer p a i n ful in exten sion or l1exion;

and home duties. He had played a fu l l game of bowls

however res i s ted isometric wrist a nd fi n ger extension

and carried the ball in his ri g h t hand without

continued to be symptomatic. Ac tive wri s t exten s ion

There had been a llare up of symp toms after working

w i th the e lbow in fu l l extension a n d pronation and

for 3 hours on his son's

w ith the arm by the side, in 9 0 degrees llexion and in

socket driver appeared to be the aggravating activi ties .

9 0 d egrees abduc tion, wa s less p a i n ful than at i n i ti a l

This exacerbation settled a fter performing his home

eval uatio n . Howard w a s adv ised t o c o n ti nue h i s nor­

exercise the next day.

mal d a i ly activi ties and to retur n i n 4 days.

d imculty.

car. Using a screwdriver and a

On p hysical exa m in a t i o n . the o n ly activ i ty t h a t reprod uced p a i n was resi sted i s o m e t r i c m i d d l e fi nger

• Treatment

e x tens i o n . There was m il d tender ness o n p a l p a t i o n of


the atta chment of exte nsor c ar p i rad i a l is b rev is a n d

Howard repor ted no d isco m fo r t w i th w riti n g b u t still

t h e assoc i a ted extensor m u scle m a s s . T h e movement

complained of p a i n with compu ter key board a n d

of active wrist exte n s io n w i t h the elbow

mouse activ i t i e s . S having a n d teeth c l e a n i n g h a d not

s i o n and pro n a tion, w i th the a rm by the side, i n 90

been pro b l e m s . He had noticed c a r ry i ng a heavy b a g

degrees flex ion and in 9 0 degrees abducti o n , was not

i n h i s r i g h t h a n d h a d aggravated h i s symptoms for 1

p a i n fu l . Wri st and fi n ger extensor muscle s tretc h was

in fu l l exten­

accessory motion of thera d io­

d ay. Regu l ar use of the presc ribed exerc ise m arkedly

now pa in-free. Passive

relieved the symptoms the next d ay.

h u meral j O i n t was still restricte d by s t i ffn ess, bu t p a i n

O n p hysic a l ex a m i n a t i o n , gri p pi n g was p a i n-free

w a s no l o n g e r evoked .

i n fu ll exte n s i o n and 90 d e g rees l1ex i o n . b u t resisted

Therapist i n tervention was the s ame as that pro­

was s t i l l p a i n fu l .

vided a t the previous sessi o n . Five sets of 10 repetitions

isometric wrist and fi nger exte n s i o n

Copyrighted Material


o f r e si s ted isometric wrist and fi nge r exte n s i o n , with each con traction held fo r 3 se conds, complete ly abolished the pain w i th all mus cl e contraction tests. Howard was advised to carry o n with the self� m o b il iz a ti o n tec h n i ques on a d a i ly b a s i s for the nex t week , or lo n g e r i f t h e el bow continued t o b e a pr o b le m . In an attempt t o prevent future rec urrences , a ten­ n is e l bow brace ( e pi co n dy l i ti s cl asp) was provid ed for u n a c c us t o m e d a c ti v i t i es i nvo lv i n g forcefu l gripping. The b r a c e w a s rec o m mended to r e d u c e t h e stress on the c o mmon extensor origin from fo rcefu l gripping acti vities . It was t ho u g h t that u n accustomed fo rcefu l use of the wr i s t a n d fi n ge r extensor a nd fore arm pronator muscles could overload the common exte n ­ s o r o r i g i n a n d provoke a n e w episode of pa i n . The mechanical role or the brace w a s to spread the forc e

of gripp i n g over the whole fo r e a r m and so re d uce the overall load at the co m mo n ex te n s o r or i g i n It h as been s h own that simi lar c l asp s can sign i fican tly i mprove pa i n - free grip strength in su ffe rers of ten nis elbow (Burton, 1 9 8 5 ) . A s t hi s e piso d e had been ca used by overs tress o f the fo rearm musculature, Howard was also p re s c r i b e d exercises for improving co ntrol of the forearm s u p i n ­ ator a nd pro n a to r muscles , as we l l as t h e wrist a n d fi n ge r ex tensor and f1exor muscles. It was ex p l a i n ed to the p a ti e n t th a t this was to prepare the el bow joint and f'orearm mu scles for fu ture forceful gri pp i ng activities. Howard was a l so advised to resume the seJf­ mobi l ization e xer c i ses in the e v e n t of recu rrence and to con t i n u e w i t h th e m [or 1 week a fter the symptoms su bside . .



What caused to you to sel ect t h e chos e n MWI"1

this case, as the p a ti en t had been referred fo r st re n g th

as you r treatment?

ening an d s tret c h in g exercises by h i s r h e u m a t o l o gi s t .

• C l i ni c i ans'


an swer

Historica lly, te n n is elbow has been a di ffi cu l t p ro bl em to treat. with a wide variety of procedures and m a n ­ age m e n t pro toco l s advocated (Cald well and Safran, 1 9 9 5 ; Noteboom et a l . , 1 9 9 4 ; Putnam and Cohen , 1 9 9 9 ; Reid and Ku s hn e r, 1 9 9 3 ) . G e n e ra l l y, treatment is pro l o n ge d and lo n g ter m o u tco m e s questio nable (Mack a nd B u rfield , 1 9 9 8 ) . When ind icated , th e MWM for tennis e lbow described by Mulligan ( 1 9 9 9 ) is a si mp le but extremely effective means o f trea ting th i s d iso rder. However, an indication for use is only determined by trial a pp l i ca ti o n o f t he te ch niqu e . Therefore, the reasons for selection of an elbow MWM fo r t re a t men t were :


Could you elaborate fu rth e r regard ing the pathobiological mechan ism fo r t h i s case of te n n i s e l bow? What did you co nsi d e r cau sed the positional fa u lt i n t h e first place and what s u bseq u e ntly mai ntained it?

• C l i n i c ians'



• i mm ed i a te abolishment of pain d uri n g the tr i a l • pr evio us experience and kn owl edge of efficacy of

the te c h n iq ue • po ten t i a l for integration into a h ome treatment

p ro g r a m m e suitable fo r the patient's prese n ta t i o n

It is p ro b a b le that the p a t ien t developed lateral elbow pain as a r es u lt of un accustomed use ( as wel l as over­ use) of the forearm pronator and the wrist and finger exte nsor muscles d u r i ng the 2 -week period he worked a s a mec h a n ic. His a ttempt at free i ng the corroded n u t also re qu ir ed sustained , excessive grippi n g , fo r ear m pron a t i o n and wrist extens i o n force . The pa ti e n t , therefore, su ffered a sudden stra in , as well as r ep et i t i ve m icrotrauma, to the musculotendinous i nsertion, thus ca u s i n g tissue damage. The consequent scar ring, possibly conSisting of granulofi broblastic m aterial s among others, subsequently became infi ltrated with free nerve e nd i ngs It is known t h at gra nu l o fib rob l a s tic materi a l laid down i n the repa i r process of te nnis elbow contains free nerve en d i ngs ( G o l d i e , 1 9 6 4 ) . I t w a s fo u n d t h a t r ep os i ti on i n g t h e u l n a and radius wi.t h respect to t h e h u merus completely abol­ ished t he patient's pa i n . It w as hy pothesized th a t .

a nd lifestyle. F u r thermore, the i mmed iate a n d marked re d u c tio n in

symptoms w i th the tech n i q ue was helpfu l i n ga i n i n g the patie n t ' s co n fi d en c e a n d co m p l i a nc e in his reha­ bilitation process . Th i s wa s p ar ti c ul a rly i mportant in

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ma l positi oning of the u l n a and radius was caused by

gl ide is di rected is d ependent o n the orientation o f the

the excessive forearm pron ation and wrist extension

concave joint su rface. often referred to as the treat­

force used to loosen the cor roded nut. This excessive

ment plane (Kaltenborn. 1 9 8 0 ) . F a i l u re by the thera­

force was not matched by adequ ate con trol of the

pist to apply the gl ide parallel to this treatment plane

a ntagon ist fo rearm muscles. particu larly the supina­

will result in compression of t h e j o i n t surfaces and

tor. T h i s i n formation . together wi t h the other fin d ings

consequently ca use pain (Mulligan, 1 9 9 9 ) . In many

from the c l i n i c a l ex a m i n a tio n . i n d icates that th is

cases. the therapist may not apply the glide precisely

patie n t ' s pain prob lem was a mech anica l nocicep tive

i n the right directi o n i n i t i a lly. If the thera pist is

disord er invo l v i n g the elbow j o i n t complex, as we ll as

unable to relieve the symptoms w i t h the glide, then

that a ri se from the common extensor ori­ the l a teral e p i c o n d y l e . A b n o r m a l posi tioning o f

subtle c h a n ges in t h e glide a n gle should be e mployed

t he musc l es g i n at

the u l n a a n d r a d i u s d u r i n g activities that involved

to abolish symptoms completely d u r i n g the accom­ pany i n g movemen t or muscle contracti o n .

con traction of the fi n ger a nd wrist exte nsor muscles,

Faulty j o i n t alignment c a n mechanicaJ ly distort

parti c u l a rly w i t h the forearm i n pro nation ( typing.

scar tissue and thus stimulate the i n situ free nerve end­

wri ting. teeth clea n i n g , sh aving . etc . ) . S i g n i fi c a n tly

ings laid d own in the repa ir process sufficiently to evoke

loaded the attachment of the extensor muscles and

mechanical nociceptive pain. Correction of the j oint

caused p a i n . Repeated overuse of the fo re arm prona­

mala l ignment by MWM may reduce the mechanica l

tor and wrist and fi n ger extensor muscles during

distor tion of the scar ti ssue and so relieve p a i n .

these activities m a i n t a i n ed the bony pos i t i o n a l fa u l t at the el bow. Repea ted abnormal l o a d i n g o f the

C o n s i d e r i ng the p roposed p o s i t i o n a l fau l t

rep airing musc u l o tendinous i n sertion maintained

mechan i s m . w h a t w a s yo u r i n te r p retati o n

sensitiza tion (cen tra lly a nd /o r peripherally) o f the

o f the phys i c a l signs t h a t suggested

nociceptors and ot her receptors in the scar tissue,

a m u s c u l ote n d i n o u s path o l ogy rath e r than

conseq uently m a i n ta i n i n g the pain disord er.

a joint path o l ogy ?

The concept of abnormal bone positi o n i n g has been proposed by Mu l ligan ( 1 9 9 9 ) as an exp l an ation fo r the purported success o f MWMs in the treatment o f

• C lini cians' an swer

chronic tenn is elbow a n d other disorders . Mack and

It is impor t a n t to u nderstand t h a t the hy pothesis o f

Burfield ( 1 9 9 8 ) Similarly hypothesized that l ack of

malpos i t i o n i n g o f the u l n a and rad i u s i n re lation

ecc entric con trol of fo rearm pronation leads to exces­

to the h u merus does not preclude

sive media l and inferior displacement o f the head of

the muscul otend inous insertion. The phYSical signs

the radiu s . which s u bsequently increases the load on

fou n d a re consistent with a musculotend i n o u s patho­


problem with

the common extensor origin at the l ateral epicondyle.

logy. as well as a n elbow j o i n t complex pathol ogy.

Eccen tric control of forearm pronation. and therefore

Malposition i n g of the u l n a and rad i u s in relation to

lateral elbow stabil i ty, is p rovided by the supinator

the humerus creates an increased load on the muscu­

muscle ( S troya n and Wilko 1 9 9 3 ) with i ts close attach­

lotendinous attachme n t during gripp i n g a n d wri st

ment to the lateral epicondy le, radia l collateral a n d

and fi n ger extension task s . Nociception arises [rom

annular l igaments (Mack and Burfield , 1 9 9 8 ) . The

mechanically evoked responses fro m receptors in

concept of abnormal humerou lnar and radiohumeral

the repairing scar tissue at the muscul otendinous

ali gnment in tennis elbow is supported by the results

attachmen t . rather t h a n from j u s t the j oi n t complex

of a single case study design by Vicenzino and Wright

itself. RepOSition i n g the u l n a and rad i u s in relation

( 1 9 9 5 ) . They demonstrated th at the lateral glide

to the humerus normalizes loadin g o n the attachment

MWM of the elbow (Mulligan. 1 9 9 9 ) , which might

during gripping and other tasks , thereby reduci n g

potentially correct the med ial rad i a l displaceme n t

mec h a n i c a l provocation o f t h e sensitized receptors

described b y M a c k a n d B u r fi e l d ( 1 9 9 8 ) . imme diately

within the scar tissue.

relieved the pain experienced during gripping tasks and normal fu nction was rapidly restored.

The fi nd i n g of increased stiffness to passive acces­ sory motion testing o f the radiohumeral j o i n t was not

However, c l i n i c a l experience indicates that close

en tirely consistent w i th a j o i n t i n s t ab i l i ty problem.

atte n ti o n to technique with respect to the a n gle and

With a n in stability probl e m . one would a n tiCipate

pl ane of the gl ide is criti c a l to the s uccess o f MWM. In

hyperm o b i l ity rather tha n hy pomo b i l i ty, unless there

a concave/convex jOint. the plane i n wh ich the MWM

was associated muscle guarding.

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H ow d i d you ga i n the pati e n t's consent fo r the

fmger extension was d imini s h e d to some deg ree . The

MWM i n terventi o n w h e n h e had b e e n refe rred

reason for this may be that the force requ ired to repos­ i tion the radius with res p ec t to the humerus fo r pain­

fo r strengthe n i ng and s tretc h i ng exercises ?

free gripping wa s

• C l i n i c ians'


less them that required for


isome tric wrist and fmger extension. This could b e

The MWM is an i n te g r a l part o f the asses smen t

process. The p a tien t was informed that in the op i n io n of th e ex aminer there was a p osi ti on a l fa u l t of the bone s that make up the elbow j oint. The relief o f p a in on M W M tes t i n g while gripping ver i fi ed th i s fi n d i n g

because gripping is a less-stressfu l activ ity for the mus­ cu lotendinous attachment at the lateral epicondy le Conseq uently it wa s p l a n ned to

co m

w i t h isometric ,"vrist and fm ger extension as

sion of treat m e n t


b ine the MWM pr og res





The patient could see that restoring the a l i g n ment o f the bones h a d a llowed norm a l p a i n fr ee functi o n ­ -

i n g o f the w r i s t a n d fo re ar m muscles . It w a s a l s o

exp la i ned that i f the techn i q u e was repea ted a num­

t h i s would permit t he mu scles to be exe rc ised p a i n l e s s ly and wou l d h a s te n the recovery ber of times

process As well . it wo u l d a l low th e p a t i en t t o p er fo r m .

h i s no r m a l d a ily d uties . Therefore,

inconsistent w i t h

MWM is not

th e d o ctor ' s req u e s t for stre n g then­

i n g e xerc i se. Grad u a ted mu scle a c t iv i t y is a n integral

par t of the treatment p ro ced ure The passive mo bi .

l ization component of


the MWM a l lo w s the exerc ise

to be p er for med w i thout pain.

• C l i n ical

reaso n i n g com m e ntary

The s e l e c t i on of MWM for the t re a t men t sheds light o n some i n te r es t i n g aspects of e x p e r t cl i n i c a l rea s o n i n g . T h is m a n ag e m e n t decision



on seve r a l re a s o n s rel a t i n g t o the past. the prese nt

and the fu ture. F i r s t . past

e xper i e nc e

with s i m i l a r

c l i n i ca l p rese n t a t i o ns . a l o n g w i t h k n o w l edge o f

prel i minary

researc h




i nfo rm e d t h e treatment decisi o n . Recog n i t ion of

t h i s partic u l a r clinical pattern i s Clssoc i a ted with

specific actions. i n c l u d i n g i n terve n t i o n s . t h a t h ave

We re you expecting t h e M W M s i nvolving gri p p i n g to have a greater effect upon res isted wrist and fi nger exte n s i o n ? Why d i d yo u th i n k that the effect was l i m i ted ?

previously been fo u nd to be productive. Second ly. the present finding of immediate a bo l i ti o n of pain with the application of MWM is


defi n i n g resu l t

from t h e ' tria l treatm e n t ' test . T h e hypo thesis o f

l o c a l elbow musculotendin ous a nd j o i n t patho l o gy receives stro n g support from this find i n g , but of

• C l i n i cians' an swe r

greater i mp o r t a n c e is the su pport it p r o v i de s fo r

Isometric wrist and Hnger exte n s ion is usu ally more

t he application of MWM for treatment purposes.

to the muscu lotendinous unit at the lateral

as su gge s t e d by past experience. Fina l ly. it i s a n tic­

e pi co n dyle tha n gripping. Clin ically. g r i ppin g is some­

ipated that i n fu tu re manageme n t the use of

times only mil dly evoca tive of lateral elbow symptoms .

MWM self-treatmen t will be valuable. perhaps to

provoc ative

wherea s isometric wrist a n d fmger extension is more

a cce l e rat e recovery and enable patients to become

fre qu e n t ly in te n se ly evoca tive. However, with Howard .

more actively i nv olv e d a n d respon s i b l e for their

grippi n g was incorpora ted in to the MWM because it is

own care. The e l i m i n a tio n of p a i n m a n i fest w i t h

e a sier to p e r for m both in the clinic and at home than

M W M is also expected to fa ci l i t ate comp l i ance

i so me t ric wrist and fmger extens ion

with therapy as t h e patient is able to


[n m a ny cases. using a MWM that involves gripping will subsequently relieve the pain on i s o m e tr ic wrist and

fi n ger e).1:ension. This was n ot the case with

Howard , al tho u g h the pain with isometric wrist and

O utco m e

results. This ability to t h i n k

ac ross



t i me-s i mu l t a ­

n e o u s l y i n t h e p a s t . presen t a n d ru tur(:,� is reflec­

tive of higher order c o g n i t ive a b i l i ties ty p i c a l o f the ex p e r t c l i nici a n .

discomfo r t but felt no need

to carry on w i t h h i s se lJ­

mobil ization n o r a ttend [o r fu rth er treatment. In the D u ring a fo l l ow-up tele p h o ne c a ll 1 mo n th l a ter,

l i g h t of this o u tcome, no fu r t h e r apP O i n tments were

Howard said h e b a d e x p e ri en ced occasional minimal


Copyrighted Material




Do you expect that further episodes will

and t i ssu e breakdown. Carefu l attent io n has a lso been


paid to p otent i al contributing fa ct o r s such as work te c h n i q ue. prevention o f overus e and overload. mainte­ nance of su pin ator eccentric control. and the patien t s

• Clinicians' an swer


active participa tion in his own managemen t . all of

wh ich may hel p to minimize recurr e nce of his p a i n

If t h e p a t i e n t c a r ries on w i t h h i s exerci se progra mme. it


is u n l i kely l h a t he w i l l h ave a re t u rn of h i s l a teral elb o w p a i n . However. i t is much more I U<e ly t h a t he w ill sto p d o i n g the exercise. It is a l s o p robabl e t h a t he w i l l under­

• Cli n i cal reasoning c o m m e ntary

la ke work a c t iv i ty in t he fu ture t h a t invo l ves overuse or u n acc ustomed use of the pronator and w r i s t and fi nger ex tensor m u scles.

a nd

The prognostic hyp oth esis here is guarded d es p ite

which m ay ca u se a retu r n of his

the excellent outcome to manual ther a py. The p oss i


sym p t o m s . Hav i n g had one incident of p a i n related to

bility that the patient will c ease self-management

this type of activity p rob a bly p red i s p oses h im to future

a nd u ndertake ill-advised work activities is r ecog n ized . However. the broad and h olis t i c approach to management. which includes ed u ca ti o nal and ergo nomic interventions . is acknowledged as h a vi ng a p os it i ve influence on the patient's prognosis. From this re spon s e it would appe ar that experience-based

episodes . p a r ti c u l arly if


n o rm a l h umerouLn ar and

radiohumeral bone a l ignment is not m ai n t a i ned . If he ex p eri en ce s a si gn ifica nt nare- up. home exerc ise alone may not be su fficient to relieve his pain and he wou ld need to re tur n fo r fur ther treatment.


In t he patient's favour a t this po i n t i s the fact that he

person al knowledge has somewhat i n fluenced this

has been educ ated about his cond i t i o n and n o w u nder­

c l i nical reasoning d ecisi on An understanding of the

stands the i mp o r tan ce of seLf-mcmagement . Howard is

various d em a n d s and priori ties in a p ati e n t s life is



aware that his prob le m o rigin ated from un a ccust ome d

largely ac q u ired from. a nd

use of the forearm musc les. le adi n g to ab n o r ma l forces

ated from. the perspective of one 's own personal

around the elbow and s ubs eq uen t j O i n t malalignment

experience of similCir situations.


o nly be truly appreci­

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Chronic low back and coccygeal pain Paul Hodges


Skye is a 39-year-old fem ale hig h sch o o l teacher who

most comfortable position was supine lying, and as

presented with a 6-month h istory of lower b ack and

such she h a d n o night pain or sleep disturbance. Skye

coccyx pai n . She had no referra l of pain laterally into

was rela tively pain-free in the morning. but her pain

her buttocks or i nto her legs a nd no anaesthesia or

prog ressively increased du ring the day. At times, she

paraesthesia. T he pain had d eveloped gradua lly over

needed to rest i n supine lyin g in t h e middle o f t h e day

a period of 2 m o n ths with no identifiable cause. There

in order to relieve her back p ain. She had difficulty in

was no history of direct trauma to the coccyx (e. g. fall

si tting throu g h long meetings and h ad to ch a n ge

or childbirth) or of prev i ous lumb ar, thoracic or lowe r

position regularly. Her work colleagues were aware of

lim b p a i n . S h e was gene rally fit and well with no

her condi tion and were suppor tive. Her main recre­

neuro logical , respiratory. gastroenterological . gyn ae­

ation a l activ i ties were read ing. swimming . socializing

cological or other musculoskeletal disorders. including

and travel. She was able to position herself comfor t­

no change in bladd er or bowel fu nction as ascer­

ably to read a n d swim m i n g did not provoke her symp­

tained thro ugh general screenin g q uestion s . Prior to

toms. However, she found it difficult to meet people

her initial physiotherapy consultation S kye h ad con­

socially because this generally involved either pro­

su lted an orth opaedic surgeon. who performed a coc­

longed Sitti n g or prolonged standing, which invari­

cygectomy. This d id not result in any cha nge to her

ably were u ncomfortable. Therefore, she had limited

symptoms postsurgery. Fu nctionally. Skye was able to

her social interaction because of the pain. In add­

continue to work with mod i fica tion to her routine

iti o n , she lived alone and was now depressed about

to a llow frequent changes in positio n . but she had

her p resent situation. She was also concerned that

required several days off work because o f pain.

she may not be able to travel long distances again

Following the surgery, a friend had recommended she

because o f her in ability to sit for long periods.

start swimming three times per week. S h e had done this and was now relatively fit.

Skye felt angry and disappointed tha t the removal of her coccyx did not resolve her pain. She felt she had

Skye's main complaint was an inabil ity to sit o r

been let down by the orthopaedic surgeon. who had

sta nd for periods greater than 3 0 minutes as a result


of centra l pain in the coccyx and lower l u mbar spine

Following the failure of the first surgery, it was recom­

area. Her pain was also incre ased by o ther sustained

mended to her that she have a revision of the surgery







positions, such as lumbar Oexion. She generally sup­

and removal of fur ther tissue. However, Skye felt that

ported herself using her a rms if she had to sustain a

this was unlikely to help and declined to h ave fur ther

position for any duration and o ften her pain would

surgery. She had accepted that she would h ave pain

increase after returning to the neutral position. Her

forever and was concerned that she might 'end up in a

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wheelchair'. It was clear that she had no understanding of the complex nature of chronic pain or of the concept of pain referral and was not cognisant of any alterna­ tive explanation for her symptoms. Furthermore, she

was unaware of what physiotherapy could olTer but reduce her pain. Her ultimate goal was to become completely pain-Iree and unrestricted in her recreational activities and travel . was willing to try anything to help



What were your initial thoughts at this stage? In particular, what hypotheses were you considering with respect to the source of the symptoms/ impairments and the pain mechanisms involved?

• Clinician's answer

resulting in repetitive irritation of spinal structures. Regardless, it would be important to consider cha n ges in the central nervous system perception and inter­ pretation of pain.


Did you consider that there were any significant psychosocial factors in the patient'S

My initial impr ession of this patient was that the coc­ cyx was probably not the primary source of her symp­ toms. This was largely based on th e fact th at there was no provocative episode related to the onset of her symptoms and that most of the painful positions and

• Clinician's answer

movements would be unlikely to impact on the sacro­ coccygeal area. In particular. the failure of the coc­ cygectomy to alter the pain suggested that it was probably not the source. There were several other options that required consideration. The location of the pain was consistent with possible somatic referral from the lumbar spine or sacroiliac joints. In addition. it was anticipated that the function of the deep trunk muscles may be compromised as a result of the pres­ ence of pain. This was hypothesized because research evidence has indicated that such a change is a rela­ tively constant finding in people w ith low back pain (at least of insidious onset) (Hodges and Richardson , 1996) and these changes can be induced by experi­ mental pain (Hodges et aI., 200la). On the basis of the mechanisms that increased and decreased her symp­ toms (such as sustained nexion) and the insidious onset of her pain, it may be reasonable to suspect disc pathology, but this is difficult to conHrm. Because of the 6-month duration of her symp­ toms, Skye had moved into a chronic pain state and as such it was likely that peripheral sources of her symp­ toms may be reduced and central pain processes are now involved. Several factors further complicated this issue. such as her depression , catastrophizing beliefs and the reduction of her leisure activities as a result of pain. However, local processes could not be excluded. particularly if the maintenance of her pain was caused by movement dysfunction/impairment,

There were several potential psychological factors that may have inl1uenced Skye's presentation. The major factor was a feeling of loss of control and uncertainty. This was compounded by the failure of the initial sur­ gery, which had promised a simple solution. Skye was also fearful for her future and had belieL, regarding the probable course of her symptoms (e.g. 'end up in a wheelchair'). She was also depressed that her social interaction and opportunity to travel were limited by the presence of pain. There is considerable evidence in the literature to suggest that mood and emotion have a significant effect on pain perception (Weisenberg et aI., 1998; Zelman et aI., 1991). Therefore. it was con­ sidered important to attempt to deal with these changes both directly and indirectly. It was planned to use t hree main strategies to deal with the psychosocial issues. The IIrst was to provide adequate education about the nature of low back pain and changes that arise when pain becomes chronic. Related discussion would also be needed to deal with expectations and misconceptions. The second was to give her back control of her situation and make her responsible for her recovery. Tal<ing an active approach to management (predominantly involVing exercise of the trunk muscles and restoration of trunk control) was considered essential for this to occur. Finally, it was planned to assist with the resolution of these fac­ tors by listening, providing support and encourage­ ment, and answering her questions.

presentation? If so, how did you plan to address these in your management?

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• Clinical

reasoning commentary


( i.e .

the psychosocial



questions c le a rly demon­

physical impairments and associated sources (e.g.

strate the breadth and depth of the clinical reason­

ing of the expert clinician. despi t e it being only early

lumbar disc): factors contributing to the mainte­ nan ce of the problem (e.g. d e ep trunk muscle dys­

in the


The responses to th es e two

c lin ic a l


Notably, specillc and

detailed hypotheses have been generated in






exercise ) . This ability to consider m ultiple hy poth e ­

ber of categories. including activity/participation

ses in multiple categories simultaneously is evidence

(e.g. ce n ­

of highly developed skills in the cognitive processing

restrictions: pathobiological mechanisms tral p a in



the patient's perceptions of her

of clinical data.


General observations

buU( of the extensor muscles in t he l umbar region.

Skye had poor posture in sitting and s tanding . with

There was a lso hypertrophy of the hamstrings and

a general appearance of having what is commonly

wasting of the gl uteal muscles. Activity of obliquus extern us abdominis (OE) was apparent at rest in stand­ ing and sitting. T his activity of OE was modulated with respiration, indicating a con tr ibution of OE to expir­ ation ( w hich is normally passi ve and dependent on

descr i bed cli nica l ly as 'low tone'. Her posture was slouched w ith


m a rked cervicothoracic kyphosis,

rounded shoulders and upper cervical extension with a 'poked' chin. In standi n g she had a long shallow lumbar lordosis extendin g to the mid-thoracic level.

elastic recoil of the lungs and chest wall). In conj unc­

anteriorly shifted pelvis th at was positioned in pos­

tion with Skye's kyphosis was a recessed lower rib cage


terior pelvic tilt and hyperextended knees. In many

(that narrowed w ith expiration) and

positions, she re lied on using her upper l i mbs to hold

lower abdomen. Relaxed breathing predOminantly

herself upright. The thoracic erector spinae were

involved the upper chest with activity of the accessory

hypertrophied and there was an obvious reduction in

i nsp ir atory muscles.





What was your interpretation of the postural

of this activity and expiration should be a passive

and breathing pattern, and its Significance to

process generated by the elastic recoil of the lungs

and rib cage (De Troyer, 1996). In tasks in which res ­

your managemen t?

piratory demand is increased, acti v ity of the abdomi­ nal muscles wiJI normally occur during expiration to

• Cl i ni c i an 's answer

assist with expiratory airflow (Agostoni and Campbell,

Several recent studies have hig hlighted the coordin­

1970). If the in creased drive for respiration is invol­

ation between the diaphragm and deep abdominal

untary (e.g. increased concentration of carbon diox­

muscles ( particula rly TA)

ide). the respiratory modulation of abdominal muscle

[or respiration a nd postura l

c ontrol (Hodges et aI., 1 997a : Hodges and Gandevia.

activity should frrst occur in TA, then the other

2000a). In norma l relaxed stand ing , there should be

abdominal muscles (De Troyer et aJ., 1990).

low l evel tonic activ i ty of TA (De Troyer et al.. 1990:

When the diaphragm contracts to prod uce ins pir­

Coldman et al .. 1987: Hod ges et a!.. 1997b): however,

ation. there should be both

there should be no or minima l res piratory mod u lation

of the abdominal wall and a bi - bas a l expansion of the

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anterior displacement



rib cage (as a result of the vertical pu l l of the costal

the lumbar spine and m otio n at t he tho racolumbar

fibres of the diaphragm an d the bucket-h and le action

junc tion and r ib cage (Gurfinkel et aI., 1971)). Recent

of the ribs (Mead, 1979)). For examp le , durin g normal

data i n dic a te that the n ormal postural compe nsatio n



relaxed res piratio n there should be abdomin a l wall

[or respi ration involves subtle movemen ts of the spine

disp lacem e n t bi-basal expansion of the rib cage, min­

and pelvis (Hodges et aI., 2 0 0 2 a) but this compensa­

imal upper chest movement and no or minimal respira­

tion may be inadequate in people with low back pain

tory activity of the abdominal muscles. When the

(Grimstone and Hodges, unpub l ished data). Al terna­



d eman d [or spi nal stab ility is incre a sed (for ex ample.

tively psychol ogical fac tors, such as those commo nly

durin g repetitive limb movement) the d i aphr agm and

aSSOCiated with chro n i c pai n. may prod uce c h anges

Tt\ should co-con trac t . with recip r ocal changes in

in breathing pattern. Stud ies have i n d icated that pos­

amplitude of ac tivity to sustain intra-abdomi nal pres­

t ural ac tivity of the trunk musc les may be affected


su re and respiration co ncurrently (concentric con­

by stress. fear and atten tion demand (Moseley and

traction of the diaphragm and eccentric contraction of

Hodg es 2001).

TA [or

inspiration and t he converse for expiration)

(Hodges and Ga ndevia. 2 000a b ) ,

sible i m plicati ons for muscle functio n and moveme n t


In S kye there was unex pe cted activation of OE ,



Ther e are several postu r al fac tors tha t ha ve pos­

expiration (rib cage depressi o n and obvious

charac teristics. which need to b e confirmed with fur­ t her examination. First, Skye's general ap pearance of

muscle ac tivi ty that was mo d u l ated with resp i ration).

hav ing 'low t one m ay h ave sever a l i mplications for

no tonic activity of TA ( prot r u d i ng lowe r abdomen)

the aetio logy of her pain and its management. It has


and a reduct i o n in the norm a l pattern of diaphragmatic

been rep orted that minor coord ination deficits are

breathing (reduced bi-basal expansio n. increased

common in people with chronic low bac k p a in lJ a nd a,

upper chest breathing). As a resu l t . most respira tion

1978). T he general appearan ce of low tone is consis­

occurred in the up per chest. The redu ction in bi-basal

tent with this proposal and su ggests

exp ans ion is IU<ely to be at least par tly a re su l t of the

have had poor muscle control over an extended period.

that Skye m ay

activity of OE. whic h l i mits rib cage expansi on. These

In ter ms of management. the likely p rese n ce of coord­

signs suggest t h at the normal co ordination of respira­

ination deficiencies and the duration of these changes

tion and postural control may have been compro­

would have rami ficatio ns for the elTicacy and speed

mised and there is excessive use of the superficial

of re-education of function of the trunk muscles.

abd ominal muscles. Clearly. more spe c i fic assessment

Secondly. Skye's stand i ng posture and changes in

of the function of TA and the other abdominal mus­

muscle bulk sugges t that she relies predominantly

cles is needed to confirm this observation. No study

on the l ong thoracolumbar erector spinae and super­

has yet conftrmed a rela ti o nsh ip between these changes

fic ial abd o m i n al musc les to move and control her

i n r esp i r a t ory p attern a n d back pain. but clinically

spine . Although contrac tion of the lumbar erector

it appears to be a common find i ng


spinae and superfiCial mu ltifi dus can produce and

experi mental ly induced acute pain has been shown

main tain the lu mbar lord osis (Bogd uk, 1997). when


to produce changes in r esp irato r y fu nction (Tandon

the thoracolumbar erector sp i n ae muscles contract

et aI.. 1997).

they produce thoracolumbar extension. The motion

The mec h ani sm for such changes is not known but

at the mid-lu mb ar and thoracolum bar regions may

it could involv e bo t h physical and psyc hologic al

be increased, placing stress on the passive elements in

mecha nisms. For insta nce, the c hanges may resu l t

the lumba r spine. This finding is consistent with the

from in creased activity of O E attempting to compen­

changes in resp i ra tory patter n and requires rurther

sate [or poor TA contro l. or alterations in movement

i nv esti gati on

coordination by the central nervo us system as a resul t


Therefore, the resp iratory and po s tural parame ters

of pain, which then causes i ncreased activity o f OE.

of Skye s presentation provide an i ndicat i o n that the

Seve ral studies have shown inc reased activ i t y of spe­

fu nctio n of the d eep tru nk musc les may be comprom­


cific trunk muscles fo l l OWing experimentally i n d uced

ised, Altho u g h further specific evaluation would be

pai n (Arendt-Nielsen et aI., 1996; Hodges e t aI.,

r equired to conl1rm these o bservations. they provid e

2001a). The cha n ges in resp iratory pattern may also

preliminary evidence of several fac tors that may need

occur in an attempt to l imit motion of the sp i ne (nor­

to be considered in the re tr ai ni ng or the d ee p mu scle

mal diaphragm atic resp i ration involves extension of

functio n

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• C lini cal reason ing commentary


observation) and p ersoo a l---c an be Linked in the con­

The very det a i le d response regarding posture and


breathing. in conjunction with the consideration of

meaning and accessibility in the clinical setting. This

psych osoci al aspects

linki ng rurther enriches the clinician's know ledge base


nicely i llustrates how the

or real-lire patient problems. thus enhancing

three types of knowledge-propositional (e.g. st.udies

th rough the development or

highlighting the coordination bet ween t he diaphragm

zation. As in this

and deep abdominal muscles for

and management of clinical problems requ i res

tural control). professional craft

organization of all three types of knowledge.

respiration and pos­ (e.g. skills in postural

Assessment or the pe l vis indicated a sl ight ly higher



higher level or organi­

the successfu l understa n ding

a rich

unremarkable. Palpation of the structures around the

iliac crest on the right side and increased anterior tilt.

lumbopelvic region was undertaken

In a ddition . Skye had hyperextended knees and elbows

picture of the patient's presentation. Piriformis was

and was generally hypermobile (she could approxi­

found to be tender bilaterally.

mate the lateral side of her thumb


to her forearm and extend her I1ngers to become parallel with h er wris t) .


to gain a general

it commonly is in

with low back pain.

Mus cle function examination Movement examin ation

The function of the deep trunk muscles was assessed

All movements 01 the lumbar spine were of greater

following initial attempts to teach Skye to contract

than average range of motion. Pain was reproduced

transversus abdominis (TA) independently from the

in the lumbar spine at the end of range of extension.

superl1cia l abdominal muscles, and the deep fibres of

lateral flexion to both sides and lateral gliding of the

multil1dus independently from the long erector spinae

pelvis in eith er direction. Lateral gl i de of her pelvis to the

and superficial I1bres of multifidus. P rio r to perform­

right gave the most accurate reprod uction or her lum­

ance or the test, it was necessary to educate Skye as to

bar spine pain. Pain remained briefly alter returning to

the anatomy and function or TA (Fig. 7.1) and the evi­

the neutral st anding position. Trunk flexion in standing

dence which suggests that the function of the de ep

and on hands and knees predominantly involve d move­

muscles may be impaired in patient s with low back

ment in the regions or the thoracolumbar junction and

pain. She was then pos i tioned in [our-point kn eeling

mid-lumbar spine.

with a lesser degree of movement in

and instructed to relax her abdomen. She had diffi­

the low lumbar spine and hips. Minimal intervertebral

cul ty relaxing her OE completely in thi s position and

movemen t or t he lower lumbar segmen ts was observed

experienced discomfort in her elbows. which were

with trunk movement in the sagittal plane. In rour­

hyperextended. The el bow pain was resolved b y pos­

point kneeling . she was unable to control the position of

itioning her with the weight of her upper body supported

the lumbar spine when moving backwards with hips towards the feet. This movement resulted in consid er­ able flexion at th e thoracol umbar juncti on.

Passive jo int movement examination and palpation On passive movement examination of the spine and pelvis, there was increased resistance to central pos­ teroanterior pressures at the L4 and L5 ver t ebra l levels. Sustained posteroanterior pressure on L4 ror more than 10 second s resulted in reproduction of the coccyx pain. Posteroanterior pressures applied to the upper

Fig. 7.1

lumbar levels were norma l or

the anatomy of transversus abdominis and the performance

had slightly increased

mobility. Unilateral posteroanterior pre ss ures were

Diagram shown to patient to demonstrate

of an independent contraction of this muscle.

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(�,...-----� Fig.7.2

Diagram shown to patient to demonstrate the

technique for palpation of contraction of transversus abdominis and how to detect through palpation whether the contraction is correct.

on her forearms. She was instructed to breath in and out and then gently and slo wly draw her lower abdom­ inal wall up an d in. Skye found this task difficult, and on observation it was apparent that most of the move­ m en t of her abdomen occurred in the upper half and

her rib cage was depressed downwards and inwards.

Both of these signs indicated that she had pre domi­ nantly contracted her OE. Findings from palpation of

Fig. 7. 3

Test for independent activation of transversus

abdominis without contribution of the superficial abdominal muscles. The patient lies prone with



pressure cuff placed under the abdomen. Contraction of transversus abdominis lifts the abdominal wall up off the cuff, resulting in a reduction in the cuff pressure. The normal response is a decrease in pressure of 4-6 mmHg. which can be held for 10 seconds and repeated.

the lateral abdominal wall and surface electromyogra­ phy recordings from electrodes placed over the distal end of the eighth rib conrlrmed the presence of exces­ sive OE activity during the performance of this task. With palpation of the abdomina l wall medial and infe­

rio r to the anterior superior iliac spine (ASIS) there was no discernible contraction of TA (deep tightening) (Fig. 7.2) and only superficial contraction of obliquus internus abdominis. To assess the con tractio n of TA more formally, Skye was positioned in prone lying with an


air-ruled cuff (Stabilizer. Chatt an ooga USA) pl ace d

under her abdomen (Fig. 7.3). When Skye atte mpte d to per for m the contraction in this position, she was unable to reduce the pressure but instead increased it from 70

to 72 mmHg. This pressure change wa s associated with the signs of superHcial muscle activity outlined above. Following education pertaining to the anatomy and

function of multifidus, Skye was taught to contract the lumbar

multifidus isometrically. Palpation of the back

muscles and multifidus revealed rigid superficial ten­ dons of the long erector spinae. The bulk of lumbar multifidus was generally reduced but eq ual between the left and right sides; it had a thickened consistency that lacked the normal elastic feel of healthy muscle ti ssue at the L4-L5 and L5-S1 levels. Attempts to contract the


Test for independent activation of the deep

fibres of multifidus without contribution of the superficial erector spinae muscles. The therapist palpates for a gentle slow increase in deep tension in the multifidus while the patient performs an isometric contraction of the muscle.

pelvic tilt co mbi n ed with contraction of the oblique abdominal muscles. The pressure in the in11ated cuff under the abdomen was increased in response to the activation of the oblique abdominal muscles.

Muscle length tests m otion

found on muscle leng t h tests

multifidus (Fig. 7.4) revealed an inability to perform this

The ranges of

task. which she simulated by performing a posterior

for rectus femoris and iliopsoas were

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m o der a tely



restricted and equal between sides. Measurement of

lumbar or coccyx pain. The straight leg raise evoked

the length of the hamstring muscles was undertaken


in two ways: passive stTaight leg raise and active exten­



stretch pain in the posterior thigh (as described

sion of the knee with the hip held in 90 degrees of nexion. Both tests revealed limitation in the range of motion (approximately 45 degrees of hip nexion with straight leg raise and 40 degrees short of full knee

Ad j acent joints No pain or movement dysfunction/impairment was

extension with the hip held in 90 degrees of flexion)

found in the hips or knees with active and passive

and stretch pain in the posterior thigh that was not

movement tests. Pain provocation tests of the sacro­

increased by passive ankle dorsiflexion.

iliac joints and pubic symphysis were negative.

Exami nation of n eurodyn ami cs

Neuro l ogical exami n at i o n

There was n o asymmetry i n range o f motion o f straight

Nothing abnormal was detected on examination of

leg raise or prone knee bend and no reproduction of

reflexes, muscle strength or sensation.



What factors do you consider have contributed to the onset and perpetuation of the patient's symptoms! Can you please explain the

1995; Wilke et aI., 1995). Contraction of TA and eleva­ tion of intra-abdominal pressure have been shown to

mechanism(s) by which each factor has

increase segmental stiffness of the spine in humans

contributed to the pathology!

• C l i n i c i an 's

particularly around the neutral pOSition (Kaigle et ai.,

(Hodges et aI., 200lb,c) and pigs (Hodges et al., 2002b). In addition, TA has been found to be active in a manner

an swer

that is consistent with stabilization of the spine, but

Skye has several factors in her presentation that may

unrelated to torque production (Cresswell et aI., 1994;

have contributed to the onset and continuation of her

Hodges and Richardson, 1997). Furthermore, changes

pathology. rirst, the changes in the activation of the

in the function of these muscles have been identified in

deep muscles are theoretically consistent with continu­

people with low back p ain (i.e. delayed onset of TA activ­

ing instability and irritation to the lumbar structures. It

ity with arm movement tasks (Hodges and Richardson,

has been argued that lack of an effectively functioning

1996) and decreased fatigue resistance of multifidus

deep muscle system would predispose the trunk to con­

(Roy et ai., 1989)). While it is dil'ficult to obtain direct

tinued microtrauma (Gardner-Morse et aI., 1995). It

evidence to show that the change in function of these

is not possible to determine whether the poor activity

muscles leads to jOint injury/microtrauma by inad­

of the deep muscles was present prior to the onset of

equate support of the spinal structures, it is hypothe­

Skye's pain, but her presentation of poor coordination

sized that this may be the case.

and poor posture suggests a long-standing history of

Instability is a continuum of change in interseg­

poor movement control. It is impossible to ascertain

mental control. At one end of the spectrum is gross

whether the change in muscle function was respon­

instability resulting from major disruption of the pas­

sible for the initial development of pain; however, it

sive structures (e.g. spondylolisthesis, burst fractures)

could be a contributing factor in the continuation of

(Panjabi et aI., 1995). At the other end of the spec­

her symptoms.

trum is poor control of intersegmental motion within

There is considerable evidence that TA aDd multi­

the normal range of movement, and particularly

fidus are important for segmental stability of the spine.

around the neutral position, as a result of minor dis­

In animal models and in vitro human studies, simula­

ruption of passive structures (e.g. minor tear of the

tion of multifidus contraction has been shown to

annular fibres of the intervertebral disc) (Panjabi,

increase stiffness of the spine and control motion,

1992). From her presentation of pain in sustained

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mid -range positions and lack of frank traum a , Skye is likely to fall i n to the latter group. This theoretical construct has derived some d irect su ppor t from bio­ mech anical models of the spine. Several authors have argued that an operational deep muscle system is esse n tial for main tenance of suppor t of the spine (Cholewicki et aI . , 1 9 9 7 : Gardner-Morse et al.. 1 9 9 5 ) . O n this basis, i t seems feasi ble that one factor con­ tributing to the perpetuation of (and perhaps even causing) Skye 's symptoms m ay be the poor contro l of spinal stability. Although we cannot (yet ) directly measure in the clin ical setting the fu nc tion of TA and multi fi d u s i n stabilizing the spine, we can ga i n some indirect indi cation of function/ dysfu nction via the hollowing test wi th the pressure cuff placed under th e abd ome n . T here is initial evidence that the abi lity to perform this test is related to the tim i ng of TA in a task that challenges postu ral con trol (Hodges et a t . . 1 9 9 6) . Second , several postural/ergonomic fa ctors present as poten tial con tTibuting factors to the onset and /or

• Clinician 's an swer The main features of Skye's pain that were suggestive of cen tral sensitization were that the pa i n had out­ lasted tissue healing time, it was sometimes unpre­ dictable, pain and relief from treatment were laten t , a n d the pain was associated with anxiety and depres­ sio n . The ev idence from S kye's presen tation tha t was inconsistent with this proposa l was the strong correl­ ation between physical signs and her pain. For instance, it was possible to reprod uce her symptoms by perform­ ance of a simple physica l test . Many other factors of her presentation (e.g. change in movemen t pa ttern , pain-reproducing manoeuvres) were also consis ten t with a peripheral source. In the case of Skye, it is crit­ ical to consider that peripheral and cen tra l chan ges are not exclusive and elemen ts of both can be present. In fact the combin ation of peripheral sensitization and cen tral adaptations that ' upregulate' the response o[ the system to pai n


likely to be equ a l ly im portant.

perpet uation of Skye's symptoms. For instance, her poor posture in sitting (increased lum bar l1exion ) and

What was you r primar y hypoth eSiS at this

standing (thoracolumbar exten sion) is likely to lead to

stage regarding the source of the patient's

excessive strain of the in tervertebra l discs and other

symptomslimpairments (e.g. back and coccygeal

lumbar stru c tures through increased i n trad i scal pres­

pain with prolonged sta nding or Sitting) and the

sure ( N achemson and E l fstrom, 1 9 7 0 ) and creep in

associated pathobiological mec h anism(s) ?

vi scoelastic passive tissues, resulting from sustained

What clinical findings support and negate this

tension at t he end of range of lumbar l1exion. In


additio n , Skye's poor posture is associated with changes in

the movemen t pattern of

the h ip-lumbopelvic

region , which may lead to increased stress on lumbar

• Cli n ician's answer

spine structures. Skye has compensated for the reduced


use of hip and lower lumbar movement by increasing

symptoms was'pathology at the L3-L4 lu mbar motion








the motion in the mid-lumbar and thoracolumbar

segment resulting [rom a combi nation o f poor control

regions. This increased movemen t may be responsible

of spinal movemen t , generalized hypermobility and

for increased stress on the lumbar segments and could

ergonomiC or postural factors. From t he evaluation , the structures involved could be either the interverte­

potentially result in repeated microtrauma. Third , there are psychological factors that may be

bral disc or the zygapophyseal joints. Lack o[ changes

maj or issue has

in sen sation', muscle strength, rel1exes and the absence

been her disappOi ntmen t that removal o f her coccyx

of pain referral to the leg indicate that spinal nerve/

con tribu ting to her presentatio n .


not alleviate her

nerve root com promise was probably not a factor. The

pai n . This has lert her feeling helpless and frustrated,

principal location of the symptoms i n t he coccyx area

and pessimistic about her chances of recovery.

could be explained by somatic pain referral.


In a previous response, you mentioned that

inner two-thirds of the intervertebral elisc, pain is more

the chro n i c nature of this patient's problem

likely to arise from trauma to the annular fi bres a nd

( ' the cause of her symptoms ' )


Because of the absence of sensory innervation of the

suggests that central pain mechanism processes

associated inl1ammatory processes (Bogd uk , 1 9 9 7) .

would be li kely.What features in her

Several factors [rom Skye's clinical presen tation were

presentation specifically supported or negated

consisten t with the disc hypothesis. First , reproduction

a pathological centra l pain mechanism?

of Skye 's pain was achieved by centraJ posteroanterior

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pressure to the L4 leve l . Secondly. on examination of

completely excl u d e coccygea l path ology as t he pres­

the movement patter n. the L 3-L4 level was identified

sure could mechanically a ffect the sacrum.

as the region of transition between an area of decreased mobility ( lower lumbar segments) and the mobile u p per

The sacro il i a c jOint

a lso

presented as a poten t i al

source of the sympto m s , through p a i n referra l . The


provocative positions of Sitting and standing both

result in increased stress on the passive elements at t h e

place stress on the sacroil iac joint from torsional forces


spine/ thoracol umbar j unction.


L 3 -L4 level. Thirdly. the insidious onset of her pain is

be tween the sacrum and i l i a . In the ftrs t ins tance, this

consistent with the commonly described clinical pres­

hy pothesis was rejected a s the pain was located cen­

entation of disc pathology. F i n ally. the provocative posi­

trally and was not elicited with basic pain provocation

tions and movements. particu larly sustained Sitting and

screeni n g tests o f the sacroiliac j o i n t ( for a review of

trunk Ilexion. are consistent with activities involving

these tests see Lee.

increased stress of the i n tervertebral disc as a res ult of

fa iled to resolve with the initial treatme n t of other

raised pressure and l oad ing.

str uctures . i t might then b e necessary to u nd ertal(e a

The zygapophyseal j o i n ts may also be responsible

1 989).

However. i f the symptoms

more compre hens ive ex a m i n ation of t h i s regio n .

for t he symptoms . Th is hy pothesis is supported by t h e

O f c o u r s e . i t is possible t h a t the periphera l sou rce

finding t h a t p a i n w a s reprod uced b y l a tera i llexion a n d

of S kye 's p a i n may n o l o n ger be p rese n t and the p a i n

extension of t h e spine. botb o f w h i c h cl ose d own the

w a s n o w perpetu ated b y cen tra l c h a nges i n interpret­

facet j oi n ts . However. several factors a re i n consiste n t

ation o f norm a l sensory i n fo rma tio n .

with this proposa l . These i nc lude central presentation of the pain. elicitation of symptoms w i th trunk move­ ment to each side a n d p a i n p rovoca tion with a central pos tero anterior pressure (and n o t with a u n i lateral pressure ) . It i s important to acknowledge t h a t these hypo­ theses are far fro m water tig ht and there i s l ittle experi menta l evide nce to conftr m the relationship between these c l i n ical com b i n ations a n d d efic i t in a specific struc t u re.


• C l i nical

reasoning com mentary

It is clear from the r espo n s e s that the clinician has n ot l i m ited or red u ced his thinking to j u s t mec h a n ­ i c a l sources o f no c i c epti ve pa i n . a l t hough severa l hypot heses are obviously considered under this

catego r y in terms of the su p p or ti ng a n d negati n g evidence. Due t ho ugh t


however. i s a l s o given t o

t he psyc hologica l fe atu res o f t h e presentation


feel i n g s of he l ples s n es s a n d fru s trati o n ) and the p o te n tial role o f c e n tral pa in mec h a n isms in the

Are there any other hypotheses you were

mai nten a nce of the patie n t s symptoms. Such '

considering as possible explan atio ns for the patien t's presentatio n ! Why did you consider these less l i kely ?


h ol i s tic and comprehensive ap proac h to manage­ ment fadlit a te s both the c1inicia n ' s a nd the patient's u nderstanding of h er clin ical problem. and should e n h ance the c hances of a succes s fu l treatment

• Cli n ician's answer

outcome. Importantly. the clin ician is also meta­

Coccyx pathology was less l i kely as there was no

cogn itively well aware of the limitations of cli nical

mechanical mecha nism for the onset of p a in ( e . g . fal l

structural diagn os e s . Such awareness is critical so

or childbirth ) . Remova l of t h e coccyx does n o t neces­

that professional theory is not accepted as sufficient

sarily excl ude tbis poss i bility as there may be ' memory ' of pai n or cenLTal changes may h ave been initiated

e vi de n ce in is own right. Convers e ly in the absence of

and still be present. However, the reprod uction of

a ttemp ting to u nderstand patients and their presen­


h ard evidence. clinicians must use existing theory in

symptoms by m a n u a l pressure to L4 is s u ggestive of

tation s while continually rem ai n i n g both critical and

l u m b ar and not coccyge a l i nvolvement. This does not

open minded toward alternative explanations.


' h a nds on' procedures wou l d be used . However, man­ u a l tec h niques would be employed to provide i n i t i a l

In coLlaboration with Skye. it was decided to take an

p ai n relief s o t h a t t h e exercises c o u l d be performed

active approach to management whereby m i nimal

o pt i m a l ly. The primary focus o f treatment was to be

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based on S kye tak ing the responsibility to restore the

musc les. The best red u ction o f activity or OE was

fu nction of her trunk muscles so as to improve her

achieved in right side ly i n g w ith a pil low betvveen her

ability to stabi lize and protect her spine. The evidence

knees; however, OE remained somewhat active and

that tra ining of the deep muscles of the tru nk is effec­

this activity was mod u lated with res p iratio n . Verbal

tive in the management of certain types of low back

i n s tructions to reduce the a mo u n t of OE activ i ty

pain was discussed, as well as the main assumptions

were unsuccessfu l . Instruction was given in rel axed

underlying this a pproach to management. Time was

d i aphragmatic breathing. With tactile feed back over

also spen t discussing the n a ture of chro nic p a i n . its

her lower ribs a nd abdome n , she was able to inspire

presentation and the problems associated with its

with basal rib c age ex pa nsion and sl i g h t abd ominal

manage me n t . The goa l of the tTa i n i ng progra mme for

w a l l movement. and then expire w h i l e mainta i n i n g

the deep trunk muscles was the restoration of the

OE rela x a t i o n .

i ndepend ent function of the muscles ( R icha rdson

most s uccessfu l ly by allowing her to palpate the

et aI . , 1 9 9 9 ) . The aim of this approach is not to teach

l a tera l aspect o f

peop l e to activate these muscles a l o n e , but ra ther to

OE. A fter several m i n u tes of practice, Skye was t hen

activate the trunk muscles in an i n teg rated

encou raged to

ma nn er


Accurate relaxation w a s ac h i eved


a b d omi n a l

breath i n


wall for activity of

con trol led d iaphra g matic

optimize the control o f t he spine. However. in the ea rly

manner fo r seve r a l breaths , clOd then gen tly a n d

stages, i t is necessary t o perform specific con tractions

s l o w ly d raw her l ower abd o men u p a nd i n . This

of the deep mu scles. so that their s k i l led activation can

i nstruction res u l ted i n

be incor porated into complex fu ncti o n a l tasks .

was instructed to reduce her e frort so as to perform a


rapid contraction of O E . Skye

con traction that was j us t perceptible and to perform i t s l o w ly. T h i s a g a i n res u l ted i n s i g n i ficant contraction

• Initial treatment

o f OE.

The i n i t i a l tre a tment i nvolved two applica tions fo r 30

S i nce a l l i nstructions re lated to the abd om i n al wa l l

seco n d s of centra l postero a n terior pressures to L4 at

resulted i n i n a ppropriate contraction of OE a nd no

grade III- ( large a mplitude movement towards the end

palpable contraction of TA , i t was decided to c h a n ge

of ra nge of movement (Maitland , 1 9 8 6 ) ) . Two app l i­

the strategy a n d teach Skye to perform a gentle co n­

c a t i o n s for

3 0 seconds of right l a teral l1ex ion PPIVMs

traclion of her pelvic noor muscles in an attempt to

(pass ive phy s i o logical i n terver tebral movements) to

fa Cilitate

L4-L5 at grade II ( large ampl i tude movemen t with­

con tract the pelvic 1100r musc les s lowly and gen tly and

o u t mov i n g into res istance (Maitl a n d , 1 9 8 6 ) ) were

to concen trate o n the anterior part of the pel vic floor


con traction of TA . Skye was in structed to

also give n . Re assessment of late ral pelvic sh ifting to

as if s topping the now of urine. A fter several attempts

the right after each appli c a tion indic ated n o change

S kye was able to perform the con tractio n . When this



slight increase in her symptoms, a n d no cha nge

in ra nge of motion.

was d o n e i n combi nation with control led breathi ng (prior to the contraction of the pelvic floor muscles ) ,

A ttem pts we re made to teach S kye to perform con­

there w a s minimal activity o f O E a n d tightening of TA

traction of TA indepen dently o f the other s uperfici a l

was palpable inferior a nd medial to the ASIS. Once she

abdominal muscles. The two m a i n d i fficulties encoun­

had contracted TA she was unable to start breathing

tered were, first, her i nabi l i ty to relax OE, which made

without increasing the activ i ty of OE. To ensure that

it difficult to activate TA independently, and, second ly,

Skye cou l d repeat the same procedu re at home, she

S kye's poor awareness of movement of the abdomi n a l

was shown how to pa lpate the lateral abdominal wa l l

wa l l . E a c h a ttemp t t o perform the contraction was

with t h e right h a n d a n d a lso ta u g h t t o d i s t i n g u i s h

associated w it h strong activity in OE and min imal palp­

between contraction o f TA and the oblique abdominal

able tighten ing of TA. Several pOSitions were tr ialed i n

muscles by palpating i n ferior and medial to the ASIS

order to ach ieve t h e greatest re l axation of t h e superfi­

with her left hand. A fter three attem pts a t performi ng

cial muscles ( p a r ticu larly OE) and op timal activation

the con tracti on o f TA fo r 5 seconds. she was no longer

of TA . It was a lso necessary to teach Skye to bre athe

able to contract TA successfu lly independ e n tly of the

w i t h o u t co ntraction of OE during expiration. Efforts in

other abdominal musc les. She was instructed not to

fo u r-point kneel i n g , suppor ted standing a nd supine

breathe for the few seconds of the con traction and

lying all resulted in overac tivity of the superficial

that t h is wou l d be inco rporated later.

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It was decid ed that Skye would have a better

chance of achieving the contraction correctly at

muscles and ach ieve our goal of improving the stabil­ ity of her spine.

home if she was o n ly to perform this exercise and left

Examination of the home exercise re v ealed th a t

contraction of the lumbar multifldus to a l a ter stage.

S kye had difficu lty i n achievin g the correct contrac­

No other treatment was impl emented in the first ses­

tion in side lying because of overactivity of OE . As a

sion a nd s h e was instr ucted to practise the contrac­

result. other positions were t ri a led. S u pported supine

tion of TA ex ac tly as she had been ta u ght three to four

ly ing was tried w ith the trunk elevated on pi llows

time per day for j u s t th ree repetitions. She was

and the elbows supported. but Skye was still unable

advised to retu rn for reassessment in 7 days.

to relax appropriately. The best relax ation of the abdomen was achieved with Skye ly i n g in prone sup­

• Second

treatme nt

S kye stated that 30


m i n u tes

ported on her elbows . The tactile contact of her ribs

wee k l ate r)

on the bed gave her ex tra feedback about the move­

after the tre atment ses­

ment of her ribs and a l lowed h er to identi fy whether

sion her pain was d i m i n i s hed a n d the reduction in

she was using OE to move her rib cage . U nfortunately.

pain l a s ted for severa l d a y s before retu r n i n g as before

this posit ion made it difficult for her to pa l pa te TA

with l i ttle chan ge in i n t e n s i ty or d u ra t i o n . S h e had

since her arms were used for support. As a n a l te r n a ­

pra cti c ed t h e e x e rc is e s d a i l y and

ti v e .


h a p py thai she

had bee n successfu L


pressure c u ff wa s p l aced u n d e r t h e abdo m e n t o

provide feed b a c k o n elevati on o f t h e l owe r a b d o m e n .

Reassessme nt of a ctive move m e n ts revealed no

The e x e r c i se i n vol ved severa l control led b re a ths fo l­

cha n g e in r a n ge o f motion i n a ny direction . n or

lowed by slow ge n tle contraction of her pelvic floor

in pain prod u c ed at t h e end of ra nge. Pain persisted

muscles. She was s ti l l u nab le to breathe w h i l e per­

for a s h o r t period a fter return i n g to the neutra l posi­

forming the contraction w i thout increasing the activ­

tion. as had o c c u r red d u ri n g the i n itial consultation.

ity of O E . It was reinforced to Skye that the exercise

Passive joint move ment examination


was aimed at p r ecis ion and not the magnitude of the

ance to central posteroanterior pressures to L 5 and

r eveal ed

p ressure change . She was also instructed to spen d

provocation o f the coccy x pain with sustained pres­

time in supine lyin g practising controlled relaxed

sure to L4 .


Reassessme nt of her ability to isolate the contrac­


bi -basal



rela xed


tion of TA ind i c a ted there was no improvement of her

Passive treatment involved application of the L4-L5

capabil i ty to reduce the pressure wit h the inflated

lateral flexion PPIVMs to the right at g rade III and

pressure cuff under her abdomen in prone lying. I n

three repetitions of sustained ( 1 5 seconds) postero­

addition. th ere w a s n o redu ction i n the overactivity of

anterior pressure to L4. Reassessment of l ate ral pelvic

OE. Assessment of the lumba r multifidus indicated

gli ding indicated

there was no change in her abil i ty to perform a con­

movement to the left . but with no maintenance of

traction of this muscle.


slight i ncrease in pain during

pain on return to the neutra l position. Muscle con­

Skye stated that she had practised the exercise at

trol was also re tested a fter the application of the

home bu t had fo u n d it very difficult as she fel t that she

m a nual techniques

was doing ' n othin g ' . In response to this she had con­

was any change i n task performance as a result

tracted the muscles with increased effort so that she

of the intervention . If manual techniques change

was aware of the contraction. Although she was able

muscle activi ty or neurophysiological mechanisms ,


determi n e



to feel that this resulted in the inappropriate contrac­

it may be possible to change control. although this

tion of OK s he fe l t that it would be better for her

has not been tested experim e n ta l l y. S kye exhibited

because it would be m a k ing the muscles stronger.

no change in perform ance follovving the manual

Skye was educated that the exercise was aimed at

intervention .

retraining the coordination of the tru nk muscles and

Skye was given adv ice on the use of a rolled towel

not at m aking the muscles stronger. She was further

for lumbar support in order to determine whether this

educated in the importance of precision in her train­

would assist her pain control during periods of sus­

ing and that practising an exercise that was not cor­

tained sitting. She was also giv e n general back care

rect would n o t imp rove the coordination of these

and lifti ng advice and adv ised to retu r n in 1 week .

Copyrighted Material


� IJ � D


Yo u appear to have s p e n t c o n s i d erable ti m e i n

was temporary. However, the improvement of her

e d u cati ng t h e pati e n t as part o f t h e manage m e n t

symptoms was only maintained for

of the p ro b l e m . D i d y o u specifi c a l l y a s s e s s h e r

suggesting t hat t he bene fi t fro m the passive manual


limited period .

u n d e rsta n d i ng o f t h e p rob l e m p r i o r t o p rov i d i ng

techniques was short term . This resiJonse did not i ncU­

these exp lanati o n s ? C o u l d you a l s o c o m m e n t on

cate that the exercise approach was u n likely to be

t h e i m p o rta n c e of e d u cati o n i n yo u r ove ra l l

beneficial , as any effect from exercise would not occ ur un t i l t h ere was a c h ange in muscle fu nction . Because

m a n age m e n t.

there had been no c h a n ge i n the deeiJ muscle function

• C l i n i c i an 's an swer

since the first treatment, because of incor rect per­

Skye was questioned directly ab out her understand­ ing o f her problem a nd infor m a l l y throug h conver­ sation . From the assessment. it was clear t h a t her u nderstanding of the problem was limited . She had previously been in formed of a simple cau se-effect rel ationship between a single tangible pathol ogy and her pain . Follow ing fail u re of the su rgery to remedy her symptoms she was not provided with any fu rther expl a natio n As we were about to take on .



self-motivated prog ramme of exercises. it was criti c a l for S kye to understand completely t h e theoretical c o n s tru ct upon wh ich this approach to management was based . Ed ucation was also needed to ensure that the exercises were performed optimally. For instance, the initial exercise that Skye was to perform does not conform to the expectation that many patients share (Le. exercise is aimed at incre a s i n g m u s cle strength ) .

formance of the exercise. it was not eX iJecled that the muscular s u pport for the spine wou l d be improved and able to control the symptoms . Therefore. the effect of the first t reatment was con­ sistent wit h the initial biomec h a nical h y po thes i s in t h a t the selected manual techniq ues had resulted in improvement of symptoms. al thoug h d e l a yed

clinical change in symptoms was not inconsistent with the approach as Skye had n o t yet successfu lly trained the system and her exercise needed re tlne­ men t. On this b a s i s it was decided to continue with the manual techniques and to persist striv ing for independent activation of TA.


What th oughts d i d you have at assessing the i n i tial treatm e n t rega rd ing her p rogn o s i s for maste r i ng an a u tomatic motor p rogra m m e of

Therefore, it was necessary to change this perception by helping Skye to understand t h e reasoning behind the performance of gentle precise co ntr a ction s



add ition . it was i mportant to ed ucate S kye about treatmen t ef ficacy ( Hides et aI . , 1 9 9 7 : Jnil et at . , 1 9 9 8 : O ' S u llivan e t aI . , 1 9 9 7) and realistic expect­ ations in order to encourage mot iv ation. Edu cation is clearly one of the main factors when embarking on a management prog ramme that is pri m a rily dependent


Fur thermore, the fail ure of t h e exercise to make a

i m p roved muscle contro l , given the d i fficu lties s h e was ex p e r i e n c i ng? Did you find it necessary to adapt or try d i ffe rent teach i ng strategi es i n res p onse t o t h e pati ent's ab i l i ty, u n dersta n d i ng a n d l earn i ng sty l e ?

• C li n i cian's an swer Foll owin g t he first experience. it became clear that it

o n s e l f- m a n a gement and independent exercise.

would be difficult to ac hieve the correct contraction


made to persist try ing for the ideal response. However.

H ow d i d you i n terpret the res ponse to the fi rst treatm ent?

of t h e deep muscles . Collabora tive ly, a decision was

i t was important to keep in mind the need to review the situation after several treatments to determine whether Skye was progressing with this demanding

• C l i n i c ian's an swe r

cogn itive approach. It was also critical that Skye did

The conclusions drawn from the initial response were

not become frustrated with the time requ ired for her

that there was a delayed ( 3 0 minute) response to the

to make a chan ge. The difficu lty in achieving the

manual techniques and that the slight increase in pain

cor rect contraction arose because, first. S kye req ui red

resu lting from the performance of these techniques

cop io us feedback and intense concen tration to be

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successful a n d . second ly. she continued to bel ieve tha t s t r e n g t h was importa n t. Beca use o f t h is . i t was neces­ sary to ta ke t h in gs s l ow l y a n d r eg u la r ly re i n force the main points regard i n g effo r t and p r ec isio n . It was also necessary to be more expl icit abo u t the treatment go a ls and manage m e n t approach . As she had poor movement p e rce pt i o n . i t was e ss e ntial t o a dapt the s trategy to prov i de a l ter native sou rces o f fee d b a ck ( i . e . p r e ss u re c h a n ge s using the pres s u re c u ff u n d e r t he abdomen ) to enha nce he r awa reness of t he con­ tr a cti on Conseq u e n t ly. there was n o ch a n ge in teach­ .

i n g stra tegy. just rei n forcement of the exerc ise a n d


Llse of a l ter n a tive strategies to p rovide feedback.

• C l i n ical

th e r api s t and patient. al ong with ex p l anat i o n and re ass u ra nce


Patie n t lear ning is a

crucial fact or

in the success of a ny treatment outcome. but par­ ticul a rly when it invo l ves self-man agement. The cl i n ic i an in this case h a s obvio usly learnt that. in c hr on i c presentations such as this where the patien t ' s own meaning perspectives. including fee l ­

ings (e.g. helplessness ) . b el ie fs (e.g. muscles o n ly req uire strengthening) and understandings (e.g. the coccyx is the p ro b lem ) are dysfunctional l impaired . .

it is often fruitless. if no t coun terproductive. to pur­ sue a course of treatment without addressing thes e issues th rough p a ti e n t education. Manual thera­

reason i n g c o m m e n tary

pists need to develop their te ac h i n g skills continu­ ally. as they would their manual sk i l l s

Manual therapists must

be good teachers. To promote cha nge s u c c e s s fu lly in a patien t s behav­ iour. and consequen tly i n t h eir p ro bl e m . requ ires a

e mplo y these skills in cultivating


• T h i rd treatment ( 1

collaborative ap pr oa c h t o clinical r eas on i ng between



and to


approach to th e ir p a t ien ts clinical pro b l e m s . '

week l ate r)

Her home programme of exercises i nvolved con­

On r e a s sess m e nt. S kye again indicated that her pain

tinuation of her TA tra i n i n g . with the addition of

had been imp r oved for several d ays a fter tre atment b u t

active h a ms t ri n g stre tc hes (i n s upin e lyi n g with her

had re tu r ned. There w a s little cha n ge i n active move­

hips be n t t o 90 de g r e es ) . Gl u teal exercises ( bridging)

ment or passive j o i n t movement s i g n s However evalu­

. were a l s o superimposed o n her attem p ted TA set t i n g .


ation of her ability to perform a n isolated contraction of

which at this stage was sti ll o n ly fair. The b ri d g i n g

TA t h is time i ndica t ed sl ight im prove me n t . Al tho u g h

exercise w a s a i med at improving the activation of the

she was u nable to r ed u ce the p ress ure in the cuff p l aced

gluteal muscles and was per fo r med [rom crook l y i n g

under her abdome n . she was able to perfor m the con­

usi n g h i p extensio n . Prior to this bridging movement,

trac tion wit h less overactivity of OE . She still req u ired

Skye was i n str u c te d to pre-contract her TA .

encouragement to red uce the amount of effort she w a s

Postura l cor rection exercises we r e also commenced

using to pr od u ce the c o n tr a ctio n a nd performed better

at this tre a tmen t sessio n . T his i nvolved correction of

witho u t feedback from the pressure di a l In vie w of

her entire sp i n a l posture. Skye's natural attempts to s i t

this. she was a d v i sed not to use t he pressu re biofeed­

or stand stra ight were associa ted with extension at th e


ba c k unit fo r tra ining and was i n s tructed in stead

thoracolu m b ar j unction rather than control of the

to u s e a mi r ro r to mon i t o r the movement of her

normal spinal curves. Postural co r rec tio n was com­

abdomen fr o m the side. At t h i s stage, she was still not


able to commence b re a th i n g while h old i n g a con t r a c


lumbar lordosis actively by ge n tly tilti n g her pelvis for­

tion of TA , a n d so she was encouraged to i n crease

ward . To ass ist her to c o ntr o l the e xt e ns i o n at the tho­

in s i t ti n g , where she was taught to control her

the number of repetitions to five. Passive treatmen t

racolumb ar j unction , she was told to hold her thumb

involved reappli cation of t h e j O int mobilizations used

o n her stern u m and li ttle fi n ger in her navel. and to

i n the last treatment with i n creased vigour a nd dura­

keep the d i s tan ce between th e se two pOi nts stable as

tion , a nd the addition of transverse mobilizations of

s h e moved. Cervical spine posture was corrected by

L4 to the left at gr a de III. As the use of the rolled towel

te l l i n g her to imagine a s tri n g p u lle d up fr o m the ba ck

h ad been fo u n d to be benefi c i a l . Skye w a s advised to

of the top of her head . Skye was encouraged to adopt

purchase a l u mb a r support for use in the

this posture at wo rk each time she h e ar d the school

meeti n gs and at the c i n ema .

car, d u r i n g

bell for classes to finish.

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� I } -


Why do yo u th i n k that the u s e of the pres s u re b i ofeed b a c k u n it was of n o val u e , if not cou nte r p ro d u ctive ? H ow d o e s its u s e d iffe r fro m t h a t o f the m i rro r ?

It was considered necessary not only to tra in the deep mu scle function b u t also to restore normal fu nction of all of the mu scles i n the l u mbopelvic reg i o n . This is critical because norma l fu nction o f these musc les

• C l i n i c ian's an swe r Altho ugh the pressure c u ff was used to provi d e add­ itional feedback a s to the success of the contra ctio n , i t unfo r t u n a tely mea nt that Skye focussed o n chang­ ing the pressure rather than the co ntracti on o f her abd o m i n a l muscles. The pressure i n the cu f[ can be reduced by several mech a n isms in addition to c o n ­ traction o f TA , such as elevation of the lower ribs a n d l1exion

• C l i n i c i an's an swe r

at t h e thoraco l umbar j u nctio n . W h e n a

reduction in press ure occ urs without a ny motion of the rib c age o r pelv i s , i t is considered to be largely a res u l t of TA contraction ( R ic hard son et a I . , 1 9 9 9 ) . However, when motion o f the rib cage o r pelvis is produced , other muscles are then i nvolved ( e . g . OE) . F a i l u re to i nstruct the patient about these o ther pos­ sible mechanisms for decreasing pressure (or fai lure to iden tify them) may result in pra ctise o f a n i n appro­ priate contra c tio n . A l t h o ugh Skye was i n s t r ucted to keep the rib cage in contact w i th t he bed, s he had fo u n d this difficult to perceive. A s a res ult, Skye had learnt mec h a n isms to reduce the pressure t h a t were not asso c i a ted with TA contractio n , no tably Ilex ion of the thoracolumbar j unction and elevation o f the rib cage by contraction o f OE. Con sequently, the pressure b i o feedback technique had encouraged a n undesir­ able contraction and had fai l e d to provide i mproved kinesthetic awareness of the con traction . By compari­ son, the mirror provided more usefu l feedback that e n abled Skye to focus o n the correct performance o f t h e contraction ( i . e . lower abdominal move ment) and to detect in appropriate strategies (e.g. rib cage depres­ sio n , obser vable contraction of OE, movement pre­

is essential to optimize the con trol of the s p i n e , as all i u mbopei vic muscles contri b u te to speci fic aspects o f stability. I n Skye 's case, the red uction in length of the h a mstring muscles acted to l imit hip motion and res u l ted i n an i ncreased demand for motion at the lumbar spine. This wo uld occ u r partic u l ar ly at the level where there was a tra nsition between the regions of h i g h and low mob ility ( i . e .

1 3 -L4 ) . By

i n creasing the length of the hamstring m uscles , the a i m was to m i n i mize fu r ther the l o a d / s tress on the lumbar spine and increase the contr i b u tion of the hip to lumbope lvic motio n . Correspon d i n gly, i t w a s consid ered desirable t o restore n o r m a l gl u teal activation to assist with the control of l u m bopelvic motio n .

Althou gh the deep muscles a re able to

control segmen tal stab i l i ty, they h ave only a l i m i ted ability to con trol the ove r a l l orientation o f the l u mbar spine and pelvis. There fore, the exercises for the hip mu scles were not expected to h ave a d i rect effect o n the control o f the d e e p tr unk m u sc les, but they were expected instead to reduce the rel iance o n l u m b a r motio n . Many therap i s ts c o n s i d e r postu ra l co rrecti on to be an al most obl igato ry part of the managem ent of the pati ent with l ow back pain. What was yo u r reaso n i ng b e h i n d t h e d e c i s i o n to i n trod uce these exe rci s e s fo r co rrecti ng S kye's postu re ? I s there ' any re search ev i d e n c e to s u pport th is approach ?

• C l i n i cian's an swe r

dominantly of the upper abdomen , a n d fa st o r j erky

Postural correction has u nderpin ned many clinical

contractio n ) . Therefore,

a pproaches . The decision to i nclude postur a l co rrec­


the pressure c u fr.

observation with the mirror provided feedback of

tion as a compo nent of Skye ' s management was based

correct and incorrect performance, and so the desired

on a number of factors. First. there are relatively con­

movement (change in abdominal co ntour) could not

sistent d a ta to argue that the loading through the spine

be simu l a ted by imprecise con tracti o n .

is more optlmal in a ' neutra l ' position with lu mbar lor­ dosis and thoracic kyphosis (e.g. McG i ll and Norman ,

What was yo u r rea s o n i ng fo r p re s c r i b i ng

1 9 9 3 ) . Early data also indi cate that posture affects

hamstring a n d g l u teal exe rc i s e s ?

factors such as disc pressure (Nachemson and Morris,

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1 9 (4 ) .

Second ly. it is s u ggested c l in ically that activity

of the s u perfici Cl I m usc l es may be affecte d by posture

• C l i n i cal

reasoni ng commentary

(or may a ffect postu re) . For example. overactiv i ty of OE

Resea rch-b ased e vide n ce , whether i t be empirica l

in associ a t i on w i th

proo f or bio logic a l bases a s discu ssed in this


de pressed rib cage an d activity of

thoracic e rector spinae musc les appears c l i n ica l ly to

response, can be used to

favou r a m i l it a ry type posture ra ther than the normal

mak i n g process rel a ted t o the management o f

inform the


neutral curves . T here is ev idence that these muscles

indiv i d u a l patients. What is crucia l . t h o u g h , is t o

a re ovefCIct ive i n m a ny people with low back pain


(Radebold et

a I ..

2()()( )). Therefore. correction o f posture

may assist in t h e re-ed ucation of normal coordination o r the t ru n k m u s c l e s .

c l i n ic a lly

i f t h e ev i d e nce is

a ppropri a te

a n d applic a ble for a particular p a tie nt . m a t u re organ ism

( di s c u ss ed


i mpl ies . n o two people will have

As the 1)

in Ch.

ex a c t ly

the same

O n e i s s u e t o c o n s i d e r i s t h a t it i s n o t normal t o

presentation give n their u nique pa st experiences

a d o p t a n e u tra l pos i t i o n a n d st ay there. A l t h o u g h th is

and curr e n t con texts . Clinical reaso n i n g must be

m ay be o p t i m a l fo r t asks that i nvolve s u s t a i n ed load­

appl i e d to resea rch-based evidence to establish the

i n g . i t is abno rm a l to m a i n tain

simil arity of the patient ' s presentation to that


ne u tra l spi n a l pos­

Lu re r i g i dly w i t h o u t va ri a t i on . It is known that the

stud ied and to administer

centr a l nervous system u ses move ment to assist

pri ately considering the u n iq u e features of the

i n the absorption of fo rces (Hodges et al . .



presentation. The effects o f

i n terven tion appro­



Therefore . normal fu nction shou ld encourage a func­

i n terven tion for a n individual patie n t sho u l d also

tio n a l range of movement. w i th specific i ns t r uctio n

be su bj ect to the same clinical e va l u a tion ( o r

for s i t u a tions when i d e a l posture may be requ ired, b u t


with a n u ndersta n d i ng o f a llowi n g t h e s p i n e to move.

i n terven tio n .

S kye 's

re tu r n





r e p o r ted

decreased pain fo l lowin g the previous tre atment, w h ich was m a i nt a i ned for a l o n ger period ( a pproxi­ ma tely 4 days ) , w i th a g radual return o f her symp­ toms over this time. She stated that t h e performance of the abdomi n a l m u scle exerc ises gave h er a subj ect­

ive feel in g o f increased con trol of her spin e. She could delay the onset of p a i n duri n g period s o f prolo n ged sitting and standing by perform i n g regu l ar TA con­ traction s . This had been p a r ticu larly benefici al d u r­ i n g s ta ff meetings a n d while attend i n g the cinema . On physical exami na tion , there was slight reduction o r lumbar pain on la teral pelviC gl i d i ng to the ri ght and decreased coccyx p a i n w i t h sustained postero an­ ter i or press u re to L4 . Reassessme n t of her ab il i ty to contrac t TA i n d i c a ted that she was still u n able to red uce the pressure with the pressure cuff placed u nder her abdome n , but she was now able to perform the contraction e a si ly without instruction o r feed­ back . Pa l p a ti on of mu l t i fid us d u r i n g performance of the pel vic rioor/TA contraction i ndicated a p a lpable bilateral contrac t i o n that was greater on the left than

th e right a nd whi c h was able to be performed in slow a n d controlled manner.



experie nce-based

Progress i o n i nvo lved teac h i n g Skye to perform the

• Fou rth treatment (2 weeks later) On



contraction i n the more func tional positio n o f s u p­ por ted stan din g and the incorpora t i o n o f breathi n g w ith t h e contraction. Breath i n g tra i ni n g i nvo lved perfor m a n ce or a contraction of TA and t h en add i n g s p e e c h (cou nting) to encourage contro lled a irflow. I t was necessary t o t a k e t h i s i n t erme d i a t e s tep before commen c i n g true b r e a t h i n g tra i n i n g because of her d i fficulty with this task. After practice holdi n g the TA co n tra cti o n w i t h s pe ak i ng , Skye was encou raged to commence bi- b asa l d iaphragmatic brea t h i n g super­ i mposed on the TA contrac tion . To assist with this integratio n , S kye was advised to p lace one hand over the l ower rib c age to give feedback o f b a s a l rib c a ge expa n sion and the other h a n d over TA i n ferior to the ASIS . She was instructed to breathe with bi-b a s a l expansion and abdom i n a l w a l l move m e n t w i th e a c h breath, rather th a n the sha llow u pper c h e s t brea th­ i n g t hat patients o ften perform in c o nj u nction w i t h t h e d e e p abdom i n a l muscle contracti o n . In terms of pro g ression of the exercise i n to fu nc­ tional positions, S kye could most effectively pe rform the c o n traction o f TA if s he stood with h e r fee t approx i m a tely 2 0 c m from t h e wall wi th h e r p e l v i S resti n g a g a i n s t t he wall. She w a s enco uraged t o do t h i s exercise thro u g h o u t th e day between c l a sses and

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to continue her training in prone ly i n g using visual feedback from the mirror. Eva luation of the postural correction exercise i ndicated that she still required a great deal of concentration to ach ieve the desired position and was finding this d i fficu lt to accompl ish at work. Passive j oint movement techn iques were reap­ plied with progression or duration or the sustai ned pos teroanterior pressure to L4 and performance of the L4-L S l ateral fl e xio n PPIVM at grade IV Transverse mobilization was repeated at the same g rade but in an increasing degree or lateral flexion of the trunk to the right to move rur ther into the range or motion. In view of the improvement in her symptoms, but considering the slow rate of change i n Skye' s abi lity to perrorm a contraction of TA , she was given 1 month to practise the exercises independen tly. She was i nstructed to increase the number and duration or the contractions according to what she was able to manage. She was also instructed to use palpation and observation of the activ ity of OE as a gUide to this progression.

Bii'i1'i§i." I&B9" i§.i_ Over the next 6 months, Skye was seen initially monthly ( ror 2 months) and then every second month. The main limitation to her progress was the slow rate of change in her trunk muscle fu nction. She required long periods between treatmen ts in order to be able to detect a change in her abil ity to perform the contrac­ tion errectively. Deep m u s c l e con tro l

After t h e fir s t month, Skye h a d mastered the ability to perform a contraction or TA independently from the superficial abdominal muscles. Additional exercises were included to improve activation of the lu mbar multiftdus. For the first exercise, Skye palpated her multifidus in Sitting and performed gentle isometric contractions in combination with TA . She required spe­ cific instruction as to the correct hand placement and feeling for the appropriate contraction. Correction of the preciSion or the exercise was required at several ses­ sions berore the exercise could be perrormed optimally. Skye was a lso taught to perform a co-contraction of these two muscle groups during more functional tasks such as wailctng. She was encouraged to palpate the muscles initially in order to determine whether they were active and then to superimpose stepping.

I n c orporation of deep and su perficial m u scles

During this 6-month period, Skye prog ressed to the stage where she could perform a contraction or TA and reduce the pressure in the cufr placed under the abdomen by 4 mmHg. At this point, exercises to retra in the coord ination between TA and the superficial muscles were also commenced. These exercises started with her positioned in crook lyi n g with the i n ll ated pressure cuff under her lumbar spine. She was instructed to let her knee gently move out to the side without changing the pressu re i n the cuff, in an attempt to i ncrease rurther the load required ror spinal stabilization wh ile promoting dissociation with limb movement. This was gradu ally progressed to sliding one leg out stra i g h t and then l i rting her leg. Al l exercises wer e performed without letting the pressure change d uring the exercise. Other exercises included si ngle limb movemen ts a nd then con tra lateral arm and leg movements i n fou r-point kneel ing. and arm movements while sitting on a ball. For each or these exercises . Skye was instructed to contract her deep muscles prior to the addition or the load or the arms and legs. She was also encouraged to adopt a con­ trolled neutral spine position (using the method she had been taught prev iously) and to maintain this during the movements. Exerc ises were progressed after she was ab le to per­ form them accurate ly. For most exercises . she required some form of feedback. either from a pressure culT or mirror. to help to ensure that she kept her spine con­ trolled. Throughout this time, Skye continued to train her TA in prone ly ing. gradua lly increasing the holding time and the number or repetitions. She also continued to train the multifidus in standing with self-palpation of the co ntraction. The use of passive techniques made no rurther change to her symptoms and were, therefore. ceased. This allowed Skye to rocus on performing the active exercise regimen.

M ove m e n t pattern co rrecti o n

Addition a l exercises were i ncluded t o c h a n ge her moveme nt patter ns so a s to increase the movement o r h e r hips during tru nk movements without associated excessive movement at the thoracolumbar j u n ction. This i nvol ved exercises i n which she corrected the posture of her trunk ( as prev iously instr u c ted) and then flexed at the hips . keeping the position of the

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tr u n k stable w i t h combined contraction of TA and

ceased t h e TA exercises for 3 days t h e n her low b ack pain wou ld retu rn . It wo u l d then take 3 days o f exer­

m u l ti fi d u s . W i t h eac h treatme n t sessio n , the d u ra t i o n o f t h e

cise for i t to again s u b s i d e . She had tested th is on at

red uction i n sym ptoms was increased, and over the

least two occasions to convince herself that there was

period of 6 months Skye described a g r a d u a l d ecrease

indeed a c a use-effect rel ationship between exercise

i n the overall level o f her sympto m s . S h e i mproved to

practice a n d the recu r rence o f p a i n . O n exa m in a t i o n ,

t he p O i n t where she experienced o n ly min imal pain

a l! active movements h a d full range o f m o t i o n , a n d

with prolonged periods o f sitting o r stand i n g , such as

pain c o u l d only b e reproduced slightly w i t h overpres­

travel i n g in a p l ane for greater than 3 hours . She was

sure o f p e l v i c glid i ng to the right. Passive movement

adv ised to retu r n in 4 mo nths for rev iew.

exami n a t i o n fa Ued to provoke a ny coccygea l pain with sustained postero a nterior pressure to L4 . S kye was advised to conti n u e a d a i ly main ten a nce pro­

F i n al p resentatio n

gramme each m o r n i n g that i n volved i n d ependent

O n h e r fi n a l presentation. S kye was rela tively pain­

c o ntraction o f TA i n prone lying a n d m u l t i fi d u s i n

free. She was a b l e to perform her work d u ties with

sta n d i n g . S h e w a s a l so given a l i s t o f 1 0 exerc ises

m i nimal or n o p a i n a n d was n o l o n ge r l i mi ted i n her

( from those s h e had been practising) that i n volved

a b i li ty to sta nd for l e n g thy periods. However, s he

pre-con traction of TA a n d m ul tifid u s with the addi­

continued to avo id sustained sitting a n d still used her

tion of slow controlled movements o f the leg o r arm .

l u mbar suppo rt when driving l o n g d i s ta nces or during

S h e w a s t o select two exercises fro m this list e a c h day

prolo nged meeti ngs . S kye comme n ted that if she

and vary them between days.

� j




How d i d you see the various d i ssociative





facilita ti n g

exe rc i ses you used contributi ng to the

changes i n m o tor c o n trol in t h i s appro ach to m a n­

ma nagement p rogramme ? H ow important was

agement. Although several other approaches to man­

the patient's cog n i t i ve awa re n e s s in fac i l i tat i n g

a gement rely on restorati o n of fu ncti o n through

the se ch anges ?

a u tomatic facilitation of the c o r rect motor pa ttern ( for examp le, Janda.

• Cl i n i c i an 's


1 9 7 8 ) , c o n temporary moto r

lear n i n g t h e o r y focusses strongly o n cognitive correc­

The d i ssociative exercises were added to the manage­ ment programme to restore normal movement o f the l u mbopelvic region by reducin g the excessive motion of the lumbar spine a nd by increasing motion o f the hip. A t the initi a l assessment. i t was noted that most movemen t with trunk n exion occ u r red at the lum bar spine, with mini m a l contribution from the h ip . The fu nctional c h a racteristics of several of t he hip muscles (e.g. gluteus maximus and hamstrings) were consist­ ent with this observatio n . Although TA and m u lti fi­ dus should be able to enhance s pinal control throughout

tio n , with accurate feedback ab out movement per­ fo rmance and outcome ( Ca r r and Shephe r d , 1 9 8 7 ; Hodges, 2 0 0 3 ; Magi l l . 2 0 0 1 ) . As t h e motor coordina­ tion /ski l l improve s . the amount o f attenti o n /cogni­ tive awareness and

feedback that is req u i red


reduced . Once the ski l l is mastere d . then m a ny repeti­ tions are required i n order to tra in the response to become a u tomatic. There is pre l i m inary evidence that trai ning the trunk muscles i n this manner does result i n a change i n a u to matic activation in fu nc­ tional tasks (J u l t et a I . , 1 9 9 8 ) .

the range of motion, any attempt to reduce the re liance on spinal movement (as op posed to hip movement)

One of the problems of predom i n a ntly

was considered to be wor thwhile. A ny i mprovement

exe rcise based treatment regime n s can be

in this regard might assist i n mi ni mizing t h e stress o n

pat i e nt compl i a n c e . What strateg i e s do you

t h e j o i n t struct ures at t h e m id-l u m b a r level t h a t could

conside r were most useful in e n courag i n g

resu l t from excessive moveme n t .

compl i ance with thi s patient?

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• C l i n i c ian's answe r

• C l i n ician's answe r

I bel i e ve that the str ate gy most useful [or encouraging

In Skye 's case, the reassessment of psychosocial issues

com pliance with Skye was education regarding the

was u n der taken by i n for m a l question i n g . I t w as c le a r

b as i s [or the exercise and the pote n t i a l benefit of the

from S kye ' s prog ress that she h a d accepte d t h e need

exercise programme. If a patient can understand what

to be re sp o ns i ble fo r her own recovery. The clinica l

the exercise aims to achieve and is prov i d ed with evi­

process req uired a great deal of mo tivation and Sk y e

dence [or its efficacy, th e n motivation wil l be increased .

responded wel l to th i s c h a l l e n ge D u r i n g co nvers a­

Another [actor of importance in this case was the rein­

tion. attempts were co n t i n u a l ly m a de to re i n fo r ce the


[o r ce m e n t of the rela tive value of the passive and active

n o n t h reate n i n g natu re o f p a i n : t h a t the p a i n was no

components of the treatment. It was essenti a l for com­

longer acting as

plianc8 that Skye took o n the o n u s o f res p o n s i bili ty for

Thro u g h q ues ti o n i n g it was obvio us th a t her a t t itude

her � provement. P atie n ts need to u nde rst an d th at

was c h a n g i n g . Her attitude t o her s y m ptoms became

th ey

m ore p os i tive

will be responsible [or a large part of the change ;




war n i n g of d a mage to str u c tures .

s h e ca t a s tr o p h i z e d less , and she no

the passive tech n iques may assist with sy mptom red uc­

longer expected to e n d up i n a whee l c h a i r . W h i l e in

tio n , but the exercise component is essen tial for m ainte­

some cases i t m ay be necessary to undertake more



nance. If a pa ti ent believes that th e pass ive tec hniques

formal meas ures ( e . g. ques t i o n n aires) , my

will mal<e them better regardless o[ wh at they do, then

S kye 's case was t h a t t he i n for m a l method was b es t as

the motivation to exercise may be red uced.

steady prog ress was observab l e ; to u ndertake more

bel ief i n

fo rmal ex a m i n a t i o n m ay h ave u n necessari l y empha­ Why does Skye appear to need regu l a r

sized the psychosocial i s s u e


exerc i s e i n order t o c o n tro l h e r sympto m s ? I s the retra i n i ng effect o n ly tempo rary?

• C l i n ician's

• C l i n i cal

answe r

Cliillcally, it appears that ma ny p a t ie n ts can cease to

exercise o nce the con trol of the deep muscles h a s b e e n restore d . I n clinical tri als t h e benefit of exercise has b ee n shown to be m a i n tained for 30 mo n t hs

( O ' S u l livan e t aI . , 1997). However, others such as Skye appear to need continued reinforcement of the contraction. This may be because of her poor general coord i n a t i o n or per h ap s an ongoing in h i b i tory process. The decision to encou rage Skye to continue wi th regu­ l a r exercise was o nl y determined from evalua tion of pr o gress and main tenance of response. althou g h so me initi a l fa ctors such as ' low tone' may h ave s uggested the need for this approach to management. In t h i s par­ tic u l ar case, the l i ke n in g of d aily bru s hi n g o[ teeth to prevent tooth decay to the training of the d ee p muscles to prevent the recurrence o[ p a i n helped to encourage

reaso n i n g com mentary

Satisfactory patie n t comp l i a nce w i t h an ongoing exerc ise progra mme is




fu ndamen t a l req u i rement

successful ou tcome in m a n u a l t herapy,

illustrated here. Poor

c o mpl i anc e



w i t h self-man­

agement regimens leads to poor self-efficacy and event u a l ly to poor t reatment ou tcom e s . Sell� m a n ­ agement n e c e ss i t a t e s t h e patient sharing responsi­

bility [or t h e ir problem, wh ich




d i mcu l t step

for some p a ti e nts with impaired or u n h e lpfu l bel iefs and u n ders t a n d i ngs a b o u t their problem and i t s

treatmen t . particula rly i f they o n ly expect or w i s h to be a passive recipient of t h e ' hea l i n g h a n d s ' o f t h e manual therapist. T h e clinical reasoning of t h e

expert clinician i n t h i s case h a s again highl igh ted the cru c i a l role of e d u c a t in g the p a tien t , especia l ly about t h e proven or likely be nefits of


self�m a n a ge­

men t prog ramme, in order to foster motiv ation and

acceptance of the need for ongoing m a i n te na n ce .

compliance, Effective skills i n comm u n ication and


the preventive ro l e o[ bru s h i n g one's tee t h ) , are a n

Ea r l i e r you noted that t h i s pati e n t h a d pote n t i a l psychosocial p ro b l e m s that you fe l t cou l d be con tri b u ti ng to h e r pain state, and yo u o u tl i n e d th ree meas u res y o u p l a n n ed t o u n d e r ta ke to a d d ress t h e m . C o u l d you c o m m e n t n ow on yo u r reas sessment of h e r psychos o c i a l status a n d wheth e r this was a p ro b l e m ?

t e a ching such as the u se of a s i m p l e ana logy ( i . e. ,

i mporta n t part of t h e armamentarium of t h e exper t manll a l therapist. It is evid ent in t h i s response that j u st a s p hy s


i c a l i m p a i rments h ave been reg u l a rly reassessed

( e . g . motor con trol ) , so too h ave psych osocia l

Copyrighted Material


impairments However, t h e

( e. g . m a l adaptive beliefs about pain ) . reassessment o f psychosocial factors

i mproveme n t . Nar rative reason ing and commu­ nic ative

m a nagement


c l a ri fyi


therefore, appl ied i n teractively and coll abora tively




to reve a l and act on the patient's m e a n i n g pcrspcc­

previously identified that the

p a t ient may have had

counse l l i n g )



manageme n t strategies appl ied for the same factors . The clinicia n



expla i n i n g ,

process and has been closely i ntertwined with

n e gotiating

li s ten i n g

has clearly been more of a n i n formal ( a lbeit contin­

tives ( see Ch . 1 ) . C h a n ge





t h i s communicative approach, and validation was

l a ck of i n s i g h t i n to the psy­

chosocial factors i n ll u c n c i n g her problem, which

ach ieved through therapist-patient common u nder­

could h ave potenti a l ly created o b s tacles to her


and consensus .

• Refe rences A gos to n i .

E. a n d C a m p be l l . E . f. M . ( 1 9 70 ) .

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t io n o f the l u m bar s p i n e a ss oc i a ted

spine s t i ffn ess i s i n creased by e l e v a t i o n

l u m b a r s p i n e sta b i l i ty i n m a x i m u m

with low back pa i n . A mo tor control

of i n tra-abdom i n a l pressu re.

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A b i omecha n ic

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rr act u re s .

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(M .D. Grab iner. ed . )

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and mo b i l i ty in po s t u ra l con tTol:

B iomec h a n ics

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Ze l m a n . D.C . .

a n d Cleeland . C.S.

Ankle sprain in a 14-year-old girl Gary Hunt


Tiffa ny is


14-year-old fe male high scho o l fres hman

who has been referred with

a dia gnosis of right

He ordered r adiogra phs o f the foot and ankle to rule out any fracture, dislocation or epi physeal abno rma l­

lateral an kle sprain. She presents as an inte l l i ge nt.

ity. Posteroante rior, l atera l and ankle mortice views

energetic youn g l a d y who has been very s uccessfu l

were t a ken and read as norma l . She was i nstructed by

in school. both scholastical ly and in extracur ricula r

the su rgeon to use the crutches with a non-weig ht­

act ivities. She atte n d ed her ll[st therapy sessi o n with

bea ring gait and to perform a nkle d orsiOexion and

her mother. who was very supportive and appro­


priately concer ned about her da u g hter's l a ck of

Tiffany was not improving and 2 weeks l ater repeat





radiographs were ord ered to see if a ny bony c h anges

improvement from a sprai ned ankle. Tiffany ori ginally inj ured her right anlde approxi­

had occurred that mig ht have s uggested


he a ling

m a te ly 3 to 4 weeks prior to this appointment. The

stress fracture. This second set also read as n orma l .

injury occurred while she was participating in

T h e su rgeon then decid ed t o refer Tif fa ny for my e v a l u­


practice session for her cheerleading/tumbling squad.

ati on and m a n a gement.

Tiffany described the mechanism of injury as an i nver­ sion anlde sprain when she landed on another team member's foot during a li f t manoeuvre. She rested for a


few moments. and a lthough the anlde was tender. she


was able to continue the work-out session. Three days

crutches and non-weight be aring on the right leg. S he

later she returned to the gym for a follow-up work-out

was very reluctant to place the foot o n the 110or. She

and reinjured

ambulated into the clinic

using ax illa ry

the s ame ankle following a jwup man­

had not been able to wear a shoe to this point bec ause

oeuvre. She landed on the outside aspect of her foot

of slight anlde and foot s we l l i n g, and bec ause of

and described hearing a 'pop', inunediately experienced

incre ased sensitivity, primarily over all her toes a n d the

severe pain and was u n able to place any weight on the

antero latera l aspect of the foo t and ankle. Tiffany was

right foot. Her coach referred her to an athletic trainer

only able to tolerate a n elastic band a ge a nd a n over­

fo llOwing the second injury. The athletic trainer saw her

sized l1eece stocking for anlde su pport and protection.

the sa me day and advised that she apply ice. elevation

She rated her pain as 0110 at rest. but with any weight

and a compression \vrap, and exercise the foot as much

bearing or pressure the pain became very intense a n d

as possib le. He a lso encouraged her to wal l < with axillary

throbbing j u s t inferior to the lateral m alleolus, with a

crutches while bearing as much weight as tolerable.

tingling p a i n located over the a n terola tera l aspect of

FollOWing 2 d ays of this approach a n d no improve­ ment Tiffany was evaluated by an orthopaedic surgeon.

the ankle (Fi g.


S.l). Upon further discussion, Tiffany

stated th at the foot would become a dark purple colour

Copyrighted Material



Throbbing pain

Fig. 8.1

Reported areas of symptoms.

and spot ted when it was in the gravity-dependent pos­ ition f or even a few seconds. The throbbing and tin­ gling in the foot and ankle also intensified when the foot was pl a ced in the d epen dent position for 1-2 min­ utes. She also related that her toes and forefoot would begin to shake sometimes. but that it would n o t l as t

� IJ D

for more than a few seconds . This appeared to occur mostly when she tried to move or position her toes or ankle. She often noted that her right toes and ankle were c ooler than on the opposite s id e . Her physician had advised her to begin a nti­ inflanunatory medication (naproxen 375 m g twice daily). which she took sporadica lly. T iffany used the medication for the first 2 weeks after the second injury and then d isconti nued it. but she was unsure whether the medication had been of any benefit. She also applied extra moisturizing lotion on her forefoot daily to overcome dryness (Fig. S.l) and maintain normal skin tex tur e . Tiffany said she had no previous history of ankle injuries or any history of spinal complaints. She hac! no present symptoms/problems elsewhere and her gen­ eral health was unremarkable . Her goal is to return to her cheerleading squad as soon as possible and to par­ tiCip ate in a cheerl ead ing competition Ln 2 weeks.


What were your th oughts regarding the mechanism of the second injury and factors contributing to the injury?

• Clinician's answer Tiffany was not exactly sure. but she thought th at

the ankle tu r ned ove r lateral ly after a jump man­ oeuvre. By her description . I felt that she had prob ab ly sustained an i nversi on ankle sprain that involved all of th e lateral soft tissue structur e s . The i n it ial injury may have compromised her proprioceptive c apabi l ities and/or modi fied her motor pattern sec­ ondary to low-grade nocicep t ive pain mechanisms. Furthermore, the activity of tumbling can be unpre­ dictable concerning l a ndings. The second injury

could have occurred because the tissues were still inflamed with slight nocice p tive pain present from the init ia l injury. What were your working hypotheses at this stage about the possible sources for Tiffany's symptoms and disability? What findings so far supported an d negated these hypotheses?

• Clinician's answer My working hypothesis at this time was that T i ffa ny had co m plex regional pain sy ndro me type II (causalgic-type pain p atte r n ) with peroneal ner ve involvement (Harden et at.. 2001: Janig and Stanton­ Hicks, 1996). She displayed ne u ral imp air men t with vascular instab i l i ty. Primary hyperalgesia from injured tissue in the ankle region, and possibly sec­ ondary hyperalgesia from adjacent uninj ured tissue Uanig and Stanton-Hicks, 1996), char a cteriz ed her pain. The trauma seemed to involve the peron ea l n erv e p rod uci ng an abn orm al state of afferent impulses (sympathetic fibres) leading to abnormal regulation of blood now (changes in colour and tem­ perature ) and sweating (dr y ness) . Distorted infor­ mation processing in the spinal cord ap pe ar ed to be possible as indicated by the ab n or mal muscle resp onse in the toes (toes sh a k in g) . Neurogenic inflammation was also considered, as were capsular trauma a nd talar dome fracture. The plain radio­ graphs eliminated any epip hyseal injury. but more sophisticated imaging would be required to r ul e out osteochondral injury co mp l etely. However, because of the lack of functional return and the perSistence of

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pain, unu s ual for a sprain ed ankl e which t y pi c a ll y heals more quickly, I co nsid e r ed neurovascular injury the dominant d i a g no stic component of her

clinic al

presen tation.

in se veral c ategorie s : • phy sical impairments and associated structure/ tiss ue sources (e.g. lateral soft tissue struct.ures) • pathobiological mechanisms. related to both


What were your aims in taking this patient's

tissue healing (e.g.

history (subjective examination)? Did

n o c ic e p t ive)

inllammation) and pain (e.g.

• factors contributing to the injury (e.g. compro-

you actively search for any psychosocial implications for the management of Tiffany's problem?

mised proprioceptive capabilities).

Early ge nerat ion of hy po theses.


in this


to understand all the factors l e a d i n g to her current

to prior experience with similar clin­ ical presentations. Expert cl ini ci ans access their wel l- de velope d knowledge base to recognize famil ­ iar in itial cues. whi c h together begin to form a clin­ ical pattern. P re vi o u s experience with such clinical

d i s ab il ity. It h el ped to di rect my cl ini c a l exam­

pattern s or presentations wi ll help to guide the sub­

largely relates

• Clinician's answer My p r im a r y aim in taking the history

state of

was to h elp me

ination. Secondary aims include d u nd e r s ta ndi ng the


mechanism of injury, the s tate of inllammation, and






acquired cl i nical data used con tin ually to

the possible p a tho bi o l o gi c al mechanisms causing

test and to refine hy pothes e s. thus further enrich­

pain and movement i mp a ir me nt. I did not

ac tively consider any psychosoc i al implications-she was a

in g the clinician's kno w led ge base.

very outgoing and ene rgetic individual. However. she

ously been further refined upon completion of the


very g o a l oriented and

why she


wa nted to understand as not g et ting bette r.

The p rimar y diagnostic hypothes is has obvi­ patient history. However, the clinician has recog­

nized that

the c li n ical findings are not

entirely c on­

sistent with the typical pattern or presentation for a

' s pra i ned ankle'. Atypical findings. notably the

• Clinical reasoning commentary

slow rate of recovery. have

The c linic ian ' s response in reg ard to m e c hanism indicates

that even at this early

stage of the patient

visit he was Simultaneously considering hypotheses


alerted him to the likeli­ with an unusual va ri­

hood that he may be de ali n g

ation of the syndrom e. proVidi n g him with


valuable oppor tunity to learn more about this clin ­

ical variation (i'om his patient.


Clinical inspection identi fied a coo ler right foot and

The foot beca me mott led when place d in

the g r a vity ­

w hic h e x tend ed up to the calf. The temp er ature was 2.0oP (1.1 0c) cooler on t h e ri gh t side, as meas­ ured by a biofeedback temperature t he rm ist o r ( the r­ mometer). The pl an tar and d ors al as pects of the l ateral part of the rig ht fo ot appe a red dryer than those of the left fo ot . Although she d e n ied any numb­ ness in her f'oot, Ti ffany had decre ased sensation to touch in the s uperfi c i a l pe r on e al nerve distribution. She was a ctually surprised to dis c ov er that, in fact.

ed ge of the examina tion table. Capillary nIling

she had less sensation in the nerve distribution.

level of discomfort. AU active movements o f the toes,


dep e nd ent pOSition. and then blanched when elevated for 20-30 seco nd s. No associated

c h a n ge

in pain was

n oted. although she described a t hrobbing sensation in the foo t and an kl e when the foot

was d an gl ed over the time of the distal rig ht great to e was pro lo n ged compared with the left s i de. Pos te rior tibial an d dor s alis pe d is puls es were pres ent and e qual bilaterally. Manual mus­

cle s tre ngth testing was deferred because of T iffan y 's

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subtalar and anlde joints were guarded and incomplete

and longitudinal axes (Elftman. 1960; Manter, 1941)


did not produce any notable discomfort and the end­


result of pain. Slight quivering of the toes was at

times noted during the initial examination.

feel was also normal. Hip and knee motion was unre­ markable. No spinal examination was undertaken on the first visit as Tiffany had no history of spinal



Assisted active movements of the ankle were measured

Right straight leg raise (SLR) without preposition­

in prone lying with the knee extended. Dorsi!lexion

ing the foot or ankle produced d iscomfort and tingling

range of motion of the left ankle was 8 degrees. but

in the right lateral ankle area at 50 degrees. Further

only 2 degrees on the right side. Plantarflexion was also

sensitizing the peroneal nerve while performing SLR

limited on the rig ht side (25 degrees) compared with

extended the discomfort and tingling into the lateral

the left (50 degrees). as measured with a standard

forefoot and toes. No increase in tingling occurred

goniometer. Active and passive ankle plantarllexion

when the tibial nerve or the sural nerve were sensi­

with associated subtalar joint supination produced dis­

tized during the SLR test (Butler.

was reluctant to move in this direction. Other active

2000; Magee. 1997). SLR testing on the left sid e was accomplished to 95-100 degrees with only a stretching sensation

foot and ankle motions were not quantified at this ses­

reported in the thigh.

comfort in the lateral anterior anlde region and Tiffany

Remeasurement of skin temperature at the end of

sion because of lack of time. The end-feel of passive cal­ produced d iscomfort in

the physical examination demonstrated the coolness

the lateral ankle region before tension was perceived.

had extended up to the mid-posterior thigh. However

caneal inversion was soft

a nd

The end-feel of calcaneal eversion was normal. Passive

the resting pain level had not notably changed follow­

movement of the forefoot around the midtarsal oblique

ing the examination.



The initial part of your physical examination was largely directed at assessing vascular structures.

So although I routinely check vascular structures. in this case I was initially struck by the coolness.

Is this a normal feature of your routine

colour changes and dryness. These observations led

examination for inversion injuries or were there

me to perform a more thorough vascular examin­

particular cues that suggested the need for this?

ation (i.e. pulse check. capillary filling time and tem­ perature measurement) .

• Clinician's answer I directed my physical examination to include an assessment of vascular structures because her symp­ toms and history suggested vascular involvement and I wanted to quantify the vascular responses. Coolness of the foot associated with a mottled appearance in the depend ent position suggested some type of vascu­ lar involvement. Dorsalis pedis and posterior tibial


W hat was your early impression regarding the structures involved. particularly the nellrovascu­ lar tissues, and the associated pathobiological mechanisms. including the stage of healing?

• Clinician's answer The history and clinical presentation of signs and

pulses were normal (ruling out arterial occlUSion).

symptoms suggested a more complicated problem

but capillary filling time was longer on the involved

than just a lateral ankle ligamento u s sprain. Colour

sid e. Dryness. coolness and the mottled appearance in.

changes. cooler skin temperature and skin dryness.

the presence of normal distal pulses suggested abnor­

along with increased sensitivity to mechanical stimu­

mal regulation of small vessel blood flow. perhaps

lation. indicated neurovascular instability.

related to altered sympathetic nerve function (Rempel et al. 1999). .





indicated increased irritability within neurovascular

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tissue s . whi ch was prob ably seco nd a r y to direct ten­


sile forces at the time of injury. It appeared that the






"P not

en tire ly consistent with the more common syn­

peroneal nerve ( both superfic i al and deep p eroneal

drome of lateral ankle Iigament.ous spra in.

sensory branches) was impl icated. The vascular

th an ignoring

structures involved may have included the lateral







unusual . dimcult to interp r e t or perceived as non­

saphenous vein and possibl y the anterior lateral

contributory to a favoured hypothesis. the clini­

malleolar artery. the peroneal artery. and/or the lat­

cian has acted upon these findings and pursued

eral tarsal artery. The pathobiological processes in the

further data to enable him to test hypothese s

neurovascular tissues tend to suggest the persistence

related to tr a uma of neuro logical and vascular

of per iph era lly evoked neurogenic symptoms (input)

struc tures. desp i te the relative rarity of

and possibly centrally evoked symptoms (processing).


injuries . A non-exp ert therapist may have simp ly

as well as' autonomic and motor (outpu t ) involve­

focussed on the obvious injured joint stru ctures

ment. as evidenced by the shaking of the toes.

and failed to recognize the potential signil1cance of

The lig a mento us tissue should have been in sta g e

some key clinical features (e.g. dr y ness of skin).

two of heal in g (subacute or granulation/fibroplasia

nor re a ll y considered why sy mptoms and signs

and just en terin g stage three of the h eal ing process ( remodel ling phase) because it was approxi­


were persisting be y ond the expected timefra me for healing and nociceptive pain.

mately 2 2 days since th e second injury. Nociceptive

Consideration of where the p a tient ' s disorder is

pain should have resolved by this point in time.

with respect to the normal stages of tissue he aling is important in recognizing whether it is following a normal course of recovery. When this is not the

• Clinical reasoning commentary

case . it

The clinician has recogniz ed the likely S igni fi canc e

consideration of factors. including pain mecha­

of those

I1ndings in

gestive of


the clinical examination sug­

nisms as

al er ts

the reflective clinici an to further

discussed here. which may be interfering

w ith the healing processes.

neurovascular probl e m and which


more secure with an elastic bandage wrapped around

Treatment on the first day consisted of neuromobi­

applic ation .

the ankle, she was encouraged to contin ue with its

lization exercise instruction. Tiffany was advised to

Considerable time was sp e nt dis cuss ing

perform 10 repeti tions of knee extension. hourly if

with Tiffany

and her mother the mechanism of injury and the tis­

possible. without any prepositioning of the ankle.

sues that could have been injured. It was explained that

The exercise could be carried out either

the presence of neurovascular instability most Iil<ely

in supine or

sitting. She was in struc ted. along with her mother.

imp licated

to perform this exercise only to

which would probably lengthen recovery time. Options


sense of ini ti al ten­

neurological tissues and

blood vessels.

sion and not iato pain. The aim of the exercise was

for ankle supports were also

to improve vascular Iluid dynamics and axoplasrnic

decided that the need would be better assessed during

now in a n on-pa inful manner. so as to enhance

the next couple of weeks.

the nutrition and mobility of the neurol ogical tissues.

instructed on how to assess skin temperature daily. par­

It was hoped this non-painful afferent input would help to start the process of normalizing the neur a l

system. TUTany

discussed and it was

Tiffany and her mother were

ticularly following exercise. thus skin temperature '

acted as a 'comparable sign' for ti ssue stress response. They were informed that the exercise should not cause


also instructed to continue partial

weight be aring as tolerated using the axillary crutches. but not at the expense of increasing pain. She was

adVised to obtain an oversized soft slipper to provide protection to the plantar foot surface. Because she felt

the right foot to become cooler. Timeframes [or healing were also discussed. as was the probability of her com­ peting with in 2 weeks. which seemed unWmly consider­ ing her current functional status. However, follow-up assessment would be necessary to mal(e that decision.

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You have obviously spent considerable time

to reverse this process. particularly considering th e

discussing the problem and its management

return of vascular supply to the nerve and axoplas­

with Tiffany and her mother.Why did you

mic fl ow. I expected the timeframe for connective tis­

consid er this was necessary?

sue repair and remodelling to be in the order of months [or full recovery. I was not concerned t h a t the vascular component

• Clinician's answer

would result in necrosis because there were palp­

Both Ti ffany and her mother were very interested in

able pedal pulses. I contacted the

the mechanisms of injury and healing. I felt that if

about my diagnosis. with which he concurred. and

they were both well informed they would be less anx­

called him weekly to give him updates on Tiffany's

ious and better able to understand what needed to


refer r i ng


be accomplished to remedy the problem. In ad dition. our health-care system limits the number of times


patient can be seen in the clinic. This situation neces­


sitates the patien t taking responsibility for their own

plan to examine the patient further at later

care, with home ex ercise and self-management likely

visits? If so, what specifically were you planning

to be essential components of Tiffany's rehabilitation

to do?

programme. r try to empower the patient and show them what they can do to promote the healing process. Once they understand the healing process, I then show them

Did you consider the physical (objective) examination complete at this stage or did you

• Clinician's answer The examination was no t complete. I intended to

what they must do to accomplish their goals and

measure calcaneal in ver sion and eversion and to docu­

improve their functi on In this case, the goals of home

ment her weight bearing by using a bathroom s ca le. r

exercise and se l f-man agement included:

also planned to evaluate her wei ght bearing with


• faci litating lluid d ynamics to assist in resolvi ng intlammation and to improve tissue nutrition • remodelling connective tissue with graded pro­ gressive movements • enhancing motor co n trol through repetitive move­ ment patterns.

the podoscope when possible and to look at the thor­ acic spine for possible dysfunction that might influ­ ence sympathetic fun ct i on I nability to weight bear .

was a Significant impairment preventing normal ambulati on


It was considered her weight-bearing

pattern on the podoscope and the magnitude of force on the scale could be used for reassessment. This was not possible on the first visit because of time


What were your expectations regarding the


timeframe for healing and what factors in the patient's presentation influenced your thinking? Were you at all concerned at this time about the vascular component to the problem?

• Clinical reasoning commentary With the expert clinician, not


ent on

• Clinician's answer

c lin i ca l

reasoning does

in isolation. While it is heavily depend­

factors or attributes i nt e rn al to the therapist

(e.g. clinical experience. communication skills), it

I was hoping that in 4-6 weeks I would see functional improvement in her weight bearing and gait, taking into consideration the neural involvement Primarily. .

the neurovascular dysfunction influenced my think­ ing. I was not absolutely sure how long it would take

is also somewhat intluenced by factors external to



inc l u ding

the attribntes of

the patient and the environment. Such factors are ev id ent in thiS case, notably

the Willingness of

Tiffany (and her mother) to participate in her

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management, the l i m i t a ti o n


the number of tre at ­

ments imposed by the health-care system, and the inevitable time restrictions of cl i nic a l work. It is apparent that the expt.rt: clinician's re a soni ng is


slightly uncomfortable at end - range compa r ed with left ro tati on.

At the second v is it

(5 d a ys l a t er) . T if fany stated that

had been faithful in carrying out her neuromobi­

lization exercises and was able to pe r f or m them with­


any notable increase in pain. She also reported

that she had only

e x pe rie n

ced on e tempo r a ry episod e

of numbness in the cU1Jde. which had ext ended up the posterior thigh.

On ex a m in a tion . the right calf was 3.0°F (1.6°C) coole r than the l e ft . but the posterior thig hs we re e q ual in tempe rature . Ti ffa ny was still using axillary crutches with a non-weight-bearing gait on the right side. A c t i ve and pass i ve

motion of the toes and an k le

were unchanged from the initial visit. During this ses­ sion . calcaneal i nvers ion and eversion were 35 degrees and 15 degrees bilaterally, respectively. Attempts to

activate the toes using a toe-curling exercise with a towel were unsuc c e ssfu l as a result of

discomfort and

lack of toe contTol . However, the colour of the foot in the dependent position w as improved . Ti rfa ny had no complaints or thor acic spine pa i n ,

but thoracic spine m obility was assessed because of

the possibility of associated symp athe t ic nervous sys­ tem inlluence (Blumberg et aI., 1997; Butler and Slater, 1994: Cl e la nd et a!., 2002). Active t h oracic


carried out in a collaborative framework with relevant parties: the pa tien t , her mother. the referring surgeon, as well as the funding body and the workplace (sec dis­ cu ssion of collaborative reasoning in Gh. ]).

spine rotation to the right was found to be limited and

Reassessin�n11.�nd' furttler . . treatment.. \I,"'1'. '(' 0 '. .....' 1i ,� . . " •


The second tre a tment session involved neuromobi­ lization exercises for the sciatic and p eron eal nerves, and this was

c com p l is h ed without any a d ver se tis­ also instructed in how t o perform toe curls using a towel an d ankle motion (plantarllexion and dorsillexion) us in g a til t board while sitting. without incr e asin g any of the symptoms. She was issued wi t h an elastic stoc ki ng to re pl ace t he el astic b and a ge and told to a

sue temperature res p ons e (Fig. 8. 2). Ti ffa ny was

remove it if her symptom s i nc rea sed.

Thoracic spine mobilization was instituted with the aim of positively i n llu en ci ng the sympathetic nervous system to facilitate neu rovascula r s tabil i ty. The first exercise re quired the patient to be pos i t i oned in hook ly i n g with her lower thoracic spine over


crosswise-positioned foam roll, while h er hands were clasped behind her neck. She was instructed to take a deep breath while in a

curled position and then to

exhale as she lowered her up per thoracic spine to the table. She was c a u tio n ed not to move into signillcant pain nor to allow the lumbar spine to extend

d uring

this movement. This exercise was repeated three times at each thoraCic spine level up to '1'6. T iffany

noted that right thoracic rotation movement was easier afterwards and less uncomfortable. Tiffany and

Neurodynamic mobilization for the sciatic and peroneal nerves: (a) starting position; (b) sciatic mobilization only;

(c) peroneal mobilization added.

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her mo ther were then instructed i n the use of an

A fo l low-up te l e p ho n e co nversation 2 d ays later

a i rbag for spi n al m o b i lization to be p erfo rme d i n the

with Tif fa ny ' s mother indicated that the new exer­

supine lyi n g positio n . The second exercise i nvolved

cises were go i n g well and the el astic stock i n g seemed

the use a foa m rol l against a wa ll for thoracic soft tis­

more comforta b le and effective th a n the elastic b a n­

sue mob i l ization. The patient lea n s on tbe roll against


the wa l l i n a stan d i n g position a n d l1exes and extends

curl exercises because of lack o f motor control. The

tissues o f the

temperature pat tern of the r ight l eg was i mproving

the knees to move the ro l l over the so ft

Ti ffa ny was still u n a b l e to p erform the towel toe

spine. Ti ffa ny was able to perform th i s exercise with­

and it was actually fee l i n g warmer. The colour of the

o u t difficulty wh i l e o n ly p ar tia l weight bearing on the

foot was improv i n g as well . The mother was

right leg. She tol erated thoracic spine self-mob i l i zation

to continue the p l a n of care a n d

without incident.

wo uld b e per formed a t the next visit.


adv ised

reassess men t



W h y d i d you s u s pect there c o u l d be

thoracic spine rotation to the rig h t side. If we could

i nvolve m e n t of the s y m patheti c n e rvous system

improve the n u i d dynam ics of the vasc u l a r s u pply

in an ap pare n t i nvers i o n i n j u ry? Could you

and the a xop lasmic llow i n the a re a , t hen this mig ht

please fu rther e l a b o rate regarding yo u r rati o n a l e

have a posi tive impact on the nu trition of the

fo r the tho rac i c s p i n e m o b i l izati on exe rcises ?

thetic fibres .

• C l i n ician's an swe r

• C l i n i cal

I wo u l d not rou ti n ely s uspect sympathetic nerve

The 'sho t

i nvo lveme n t but her symptom presentation s u ggested

spine to help to


reaso n i n g commentary


in the dark'-that is, treat i n g the t horacic al lev iate the foot a nd ankle symp­ toms-is an examp l e of lateral th i nking on the part of the clinician. Although arguably an unlikely

fibres . This was rather a

a ssociation , despite the pathoan atomical rationale

d ark' but the rationa le relates to tho racic spine impairment i n nuencing the s ympathetic c h a i ns

processes tha t the profession al craft k nowledge of

w i t h i n that anatomical reg i o n (Blumberg et a l . ,

ma n ual therapy has

1 9 9 7 : Butler and S l a ter, 1 9 9 4 ; Cl e l a nd e t a I . , 2 0 0 2 ) .


that I consider that poss i b ility. The colour, tempera­ ture


sweati ng

c h a n ges

i nvolvement o f sympathetic

indic ated

' s h ot in the

given , it is largely through such lateral thinking developed. Neural mobil ization 20(0), repeated movements ( McKenzie,

I w a s trying t o s e e i f t here was a n assoc iation between

1 9 8 1 ) , mobilizations with movement (Mu lligan ,

thoracic spin a l mobi l i ty a n d her symptom complex .

have resulted 'outside of the box ' and reflecti ng about what t hey h ad found. Both the lndividual manual therapist and the community of manual therapis t s grow from suc h insights.

My hy pothesis w a s th a t maybe j oint a n d connective tissue res triction i n the thoracic spine m i g h t h ave h ad a contri b uti n g i nll uence on sympathetic d y sfunc­ tio n . This was suppor ted by the finding o f decreased

from a clinician d aring to thi n k

able to wear a sandal fo r the first time but still needed to


• T h i rd visit

1 9 9 9 ) and many other interven tio ns

use crutches, a l t hough she could move aro und with some weight throu gh the foot. She a l so related that

( 1 week l ater)

her toes seemed to h ave increased sensitivity an d that

Ti ffany reported less colour ch a nge \!\Iith the depe ndent

her thoracic rota tion had improved and wa s more

foot position and that the foot was warmer. She was


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Phys ica l ex amin ation revea led

ankl e mo tio n was

improving both in quality and q u an ti ty. espec i a lly right a n k le pla ntarnex ion ( 3 5 d e gr e es ) . The temperature o f the righ t c a lf was n ow o n ly l . oop ( 0 . 6°C)

coo ler than the left. C a p il l ar y mUng time in the right g re at toe was eq u a l to t h e left . Ti ffa ny was also able to f1ex he r toes a nd perfor m toe c url in g with a towel and pick-up p a ckin g popcorn with her toes. Thoracic spine right rotation was now equ a l to l e ft rotation w i t h o u t a ny d isc o mfo r t . The n e w fo u n d ab i li t y to bear we i g h t enabled the object ive assessmen t 0 1' we i g ht bearing usi n g a b ath ­ room sca l e . R i g h t foo l pressure applied to a bath room s c a l e while s i l t i n g measu red 1 2 pou nds ( 5 . 5 kg) com ­ pa red with 4 5 p ou n d s ( 2 0 . 5 k g ) o n the le ft . Ti ffany was even a b l e to ride a s ta ti o n a ry bi cyc le fo r 1 5 m i n ­ u tes without pain. Ti ffa ny re c o g n i z e d a n d a c c e p t e d that p ar t i ci p a t ion i n the u p c om i n g cheerle a d i n g competi tion was not go i n g to be possible. She w a s instructed to con tinue her home exerc ise programme as prev i ously outlined and to u til ize a stationary b icycle. progressi n g up to 2 0-3 0 mi n u tes o f cyc li ng d a ily.

• Fourth


scale press test in sitting measured 18 p o u nd s ( 8 . 2 kg) o n the r i g h t side. Ti ffa ny 's wei g h t-bearing ability was fu r t he r evalu ated using a podoscope (a p lexi g lass sta ndin g box that al lows the opportu n i ty to observe an i n d iv i d u a l 's we ig h t - b e ar i n g patter n ) . S h e demon­ strated decreased pressu re in both t h e heel and fore­ loot ( P i g . 8 . 3 ) . T i b i a vara i o s i m u l a ted s i n g l e l i m b stance meas­ u red 1 0 deg r ees bilatera lly. T h i s compared favo u ra b ly with the c a l c a n e a l eversion of 1 5 degrees meas ured d u ring the second v i s i t . In other wo rd s . she did not have a v arus calcaneus t h a t would pred ispo s e her to a n ld e spra i n s . L iga m e n t testing of t he rig h t a n terior talofib u l ar ligament r ev e a le d s l i g h t l a x i ty c o mpa r e d with the left a n kle. A l e g - h i n d fo ot orthosis was fabr icated to prov ide stabiliza tion and proprioceptive input to the a n k l e r egi o n ( F i g . 8 . 4 ) . T i ffa ny was able to s t a n d mo re

visit ( 1 week later)

she was c o n t i n u i n g to improve and was p l ease d with her prog res s . She was able to place more we ight through the ri g h t leg during waU(­ ing; the colour of the foot was s ti l l i m prov i n g a nd it was becomi n g less hyperse nsitive . The mo ther had Tiffa ny repor ted that

noted normal temperat u res in the calf a n d ankle.

On e x a m i n a ti on . the tempera t u re patterns were now no rm a l . The righ t SLR had i m proved to 70 degrees before t ight ne ss was perceived and the n e u ro ­ dynami c test for the perone al nerve was less provoca­ tive . Active right anlde dorsiflexion was now 1 0 d e gr ees

F i g. 8 . 3

a n d pla ntarnexion was 40 degree s . The b a t h room

heel and right forefoot p ress u re (arrow) .

Fig. 8.4

Leg-h i n dfoot orth o s i s : (a) l ateral v i ew;


Podoscope i mage d e mo nstrating d e c reased right

m e d i a l vi ew; (c) posterior v iew.

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comfortably wi t h the orthosis and was able to ap ply

related that the bicycle exercise seemed to be very bene­

5 0 pounds ( 2 2 . 7 kg) of force in a standing position

ficial and that pain was no l on ger a

without n o table pain pro du c ti o n . A t tttis point she

incl uding dur i n g plan tarfl exion and s u p i nati on of her

was advised to i n crease her weigh t-bearing activ ity. Addi tional instruction inclu ded various SLR exer­ cises (no weig h t and 1 0 repetitions per positio n ) ,

Si g nificant i s sue


foot. Her gai t was now accomplished without crutches and with o nly a slight limp. For long distances, how­ ever, she still preferred to use one cru tc h .

resisted a nkl e p l ant ar fl ex io n a n d thoracic ro tation

O n examination, the limp appeared t o b e related t o

u s i n g res istive e las tic exercise bands (repeated to

prolonged heel con tact dur i n g the terminal stance

fat igue) , and the use of a b at hr o o m scale for visual

phase o n the ri gh t leg. The bathroom scale test in stand­

feedback on progressive wei g h t beari n g in sitt i n g and

ing prod uced 90 pounds (40. 9 kg) without pain on

s t an ding pos itions .

the right side. The podoscope examination revealed

Tiffany was also ins tructed to

s ti ll lacked

wear the l e g -hi n d loo t orthosis thro u g h o u t the day

improved pressure u nder the toes. but she

an d to watch for any s i g n s of s k i n irritation . She was

appropriate pressure under the fLrst meta tarsopha­

encou raged to i ncrease her amb u lation and decrease

lan geal joint. No swelling was noted in the foo t and

her relia nce on the crutches .

anlde and the skin appeared healthy without evidence of dryness. Sl ight discomfort and weakness was noted

• Fifth visit ( 1

with res i s ted peroneus longus mu scle testing. Other

week later)

muscles tested around the anlde were normal . except for

Tiffany repor ted s i g n i ficant functi onal im provement

right gastrocnemius/soleus , which was sli ghtly weak

with ambu lation . She was able to ambu late with one

compared with the left . Right SLR reached 80 deg rees

cru tch for long distances and even ta ke

before tightness and slight lingling was produced.


few steps

without any ambu latory device for shorter dis tance s ,

all with o u t a n i n crease in pain.

Ti ffany was ins tructed t o cont i n ue her home exer­ cise progra m me and progressively inc rease stress to

The temperature patterns were nor ma l and shi ft­

the tissues , al ways bei n g guided by pai n .

ing her wei g ht to the right leg in s ta n di ng registered 70 pou nds ( 3 1 . 8 kg) on the ba thr o o m s cal e . Ri g h t SLR was a lm os t equal to the left , and right anlde motion

• Fi nal visit (three weeks later)

had improved to 12 degrees for d orsiO exion and 4 7

Ti ffany had been re-evaluated by the re ferring phys­

degrees for p l an t ar flex i o n without any pain. Tif fan y

ician since the prev ious visit. He was p lease d with her

was now able for the first time to stand on her right leg

prog ress and decided to di sch arge her from his care.

le g balance) for ap prox i mately 5 seconds while weari n g the orthosis . w i th o n ly one fi n ge r assisting

Tiffany no ted that pain was no lo nger an issue. She

her balance. The podoscope examination indicated

ing with prolon ged weight beari n g . It was re p or te d

( s i n gle

improved heel

and forefoot p ressure, but still lacked

good pressure under the fLr s t m e ta t ar so p h alange a l

experienced only occas i o nal arch fa t i gue and cramp­ the temperature, skin tex t u re and skin colour were normal, and she no longer n eeded the cru tch . Physical ly she demon s trated im p rov ed active con­

j oint and toes. The addi tion of the o rthosis fabr icated du ri n g the

trol of her toe and ankle muscles . Neurodynamic test­

previous v i s i t seemed to have Sig n i ficant ly improve d

in g of t he right peroneal nerve was improved to 8 5 degrees before the onset of tigh tness and s l igh t tin­

Tiffany 's weight-bearing status. S h e was encou raged to con t i n u e her home exerci se programme and to

gling. Temperature patterns continued to be normal.

concentrate o n b alanC ing activities and a normal

Tiffany was able to ambulate w ithout the leg-hin dfoot or thosis , b u t she stUl felt more con fident w h i le wearing

heel-toe gait pattern using one crutch .

it. Her gait demo nstrated good

• Sixth visit (one week later)

noted was improving. S i n g l e leg balance was accom­

Tirfany was now apprOximately 9 weeks post-inj ury and was able to wear a regular shoe

fu n c ti o nal velocity and

the late hee l-off in terminal stance phase previously

for the fLrs t time,

plished for abo u t 5 seconds w i thout a her balance. She still had difficulty

fi n ge r assisting pe r fo r m in g a heel

alt hough she continued to wear the le g-hindfoo t or tho­

rise on the right leg because of wealmess and possibly

sis . She felt that the orthosis allowed her to ambulate


more effec ti vely and with min imal discomfort. S he also

revealed symmetry between the fe e t (Fig. 8 . 5 ) .

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(proprioce p t i o n )



exerc ises .

S h e was a lso instructed in r e t r o -w a l k i n g and ec ce n­ tric l o a d i n g exercises for the a nkle pl a ntarfl e xor s to fa cilit a te s tren g t h e n i n g of

the non-contractile tissue

components as we ll as the c o n tractile elements of the muscles . It was emphasized t h a t pa i n s h o u ld gui de her exercise and activi ty. She was also encoura ged to co n ti n u e monitoring temperature as a n indica tor of tissue stress .

Approx im ately 6 mo n t h s a fter the inj ury, Ti ffa n y participa ted in a cheerJ e a d i ng squa d competi tion w i t h o u t p a i n , using the leg-hind foo t o r t h o s i s , a n d fig. 8 . 5

Podoscope image demonstrating symmetrical heel

a n d forefoot pres s u re .

wi n n i n g the state c ha m p ions h i p for h e r schoo l's d ivi­

sion. At 1 3 m o n t h s after the i nj u ry, s he considered herself to be 900ft) norm al and at 2 2 m on t hs a fter i nj u ry she cons idered herself to b e 9 8 % n orm a l . with

Ti ffany and her mo ther re lt c o n fident that s he

the o n ly compl a i n t bei ng s l i g h t nu mbness over the

could co n ti n u e on the h o me exerc ise p ro g ra m m e w i t h occas i o n a l t e l e p h o n e u p d a t es on her pro g re s s .

dorsolateral aspect o f the foo t . She continues to we a r

T i ffa ny

lea d ing activities.


adv i sed

to concen trate


b a l a nce

a sort ankle s u p p o r t d u ring p a r ti c i patio n i n che e r­



What is your long-term prognosis for

o rg a n iz e d . Expert cli n ici a ns possess a

Tiffany ?

cl in ic al pa t t e r n s d eri ved fr o m


rich store o f

combination of

pr o p o s i ti o n a l ( research-based) and non-proposi­

• Cli nician's answer

t i o n a l (professional craft and person a l ) knowledge.

Ti ffa ny has a good long-term prog nosis . Des p i te h av­ i n g s i g n i fi ca n tly i n j u red mult i p l e tissu e s , she is now

fu l ly ru nctiona l . w i th o nly s l i ght persisting numbness over the superficial p erone a l ner ve d i stribu ti o n i n the roo t. However. her cheerl ead i n g a ctiv i ti es . which include t u m b l i n g , cou l d possibly open her up to rein­ j u ry in t he fu tu re. The ankle support s he uses pr o b a ­ bly assists by prov idin g additional propriocep tive inpu t and g iv i n g her confid ence d u r i n g cheerle a d i n g

activ ities.

U s u a l ly. examination and man agement of a n kle spra ins i s straightforward given t h a t

most will

resolve t h r o u gh normal he a l ing processes, with

advice and minimal i n t er ve n t i o n typic a l ly bein g a l l that is requ ire d . Nevertheless. as this c ase


trates , p r ob l e m s can present in mul tipl e ways ranging from simple to co mple x , as in a l l areas o f the b od y. Hence, there are no recipes for examina­ tion or m an ageme nt that will apply across the ful l spectru m of possib l e pr esentati o n s .

Recognition and m a n ag emen t of more complex a n k l e spra ins, as in th is case. requires adv a n c e d

• Cli n i cal

reasoning commentary

This case. like

the others, h i ghl i gh t s t he specia li z e d


kn owledge manual therapists require to p racti se at the h ig h es t leve l . H owe ve r, as discussed in C h a pter 1 , it is not how much an i ndividu a l


som a t ic ,




anatomy, pathobiological p a i n and tissue mecha­

knows that i s

impor t a n t . but rather how that knowledge is

nisms , specialized exam i n ati o n proced u res ( e . g .

t herm ist or assessment. n e ur o dy n a mic assessment s pe c ific peripheral n erves , ankle and

bi as e d to

foot biomechanics a s sessment) a nd specializ ed

man agement p ro ced u r e s

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( e . g . o r tho t ics) . This


advanced knowledge i s not retained in abstract

kn owledge across different

academic con structs . I n stead expert clinicians pos­

meanin gful way. This level of knowledge o rga n i za­




clinica lly

sess highly developed knowledge bases where these

tion c a n not be ach ieved from books or j o u rn a l s

d i fferent


a reas




interli nked


a cq u i re

t heir clin ically

releva n t


kn owledge orga nization t h rough t h e i r n ever-end ing

the hypothesis categories discussed i n Ch apter 1 are

ref1ection a n d i n tegration of the ava i lable research

through clinical patter n s .

It is our belief

a usefu l strategy for fac ilitating

this linking of

and experience-ba sed evidence .

• References B l u mberg.

H . . Hoffm a n . u. . Mo h a dj e r. M .

a nd S c h e r e me t . H . ( 1 9 9 7) . Sym pathetic nervous syste m and p a i n : a c l i n i c a l re-appraisa l . B e h av i o ra l

and Brain S c ie n c e s . 2 0 .

4 2 6-4 3 4 .

Bu tler. D . S . ( 2 0 0 0 ) . T h e S e n s itive Nervo u s System. Ad e l a ide . Austra li a : Noigroup Press. Butler, D . S . and S l a ter.

H. ( 1 9 9 4 ) . Neural

i nj u ry i n the t h o rac i c s p i n e : a c o n ce p t u a l basis for ma n u al t h e ra py. [ n PhYSical T h era py of the Cervical a n d Thoracic S p i n e s , 2 n d edn ( R . Gra n t. ed . ) p p . 3 1 3-3 3 8 . Ed in b u r g h : C h urch i l l Livingstone.

Cleland , J .. Dura l l . C. and Scott, S . A . ( 2 0 0 2 ) . Effects of s l u m p l o n g sitting on

pe r i phera l sudomotor aod vasomotor fu n c t i o n : a pi l o t study. Jou r n al of M a n u a l and M an i p u lat ive Therapy, 1 0 , 6 7- 7 5 . E l ftman , H . ( 1 9 6 0 ) . T h e tra n sverse ta r s a l

Manter, J.T. ( 1 9 4 1 ) . M ovem e n t s of the s u b ta lar j o i n t a n d tra n s verse tars a l joints. A n a to m ic a l Record . 8 0 , 3 9 7-4 1 0 . McKe nzie, R . ( 1 9 8 1 ) . T h e Lumbar S p i n e .

joint and its c o n tTol. Clinical

Mec h a n i c a l D i a g n o s i s fi nd Therapy.

Orth opedics and R e l a ted Resea rch . 1 6 ,

Lower H u t t , New Zea l a n d : S pi n o l

4 1 -4 6 . Hard e n . R . N . . Baron, R . a n d Ja n i g, W. (20 0 1 ) . Complex Regional Pain S y n d rom e . Seattle, WA : [ASP Press. Jan i g . W. and Sta nton-Hicks,

M. ( 19 9 6).

Rellex Sympathe tic D ystr o p hy :

A Reappra i s a l . Se a tt le , WA : [ASP Press. M agee, D.J. ( 1 9 9 7 ) . Orthopedic PhYS i c a l As ses s me n t . 3rd ed n . London: Sau nders.

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P u b l ic a lions.

B. ( 1 9 9 9 ) . M a n ua l Thera py. ' N AG S ' , ' S NAGS ' , ' M W Ms ' , etc . . 4 t h ed n , Wel l i ngton, N e w Zea l a n d : P l a n e

M u l li g a n .

View Press.

R e m pe l . D . . D a h l i n , L. and Lu ndborg. G. ( 1 9 9 9 ) . Pathophysiol ogy of nerve compressi o n s yn dr o m e s : respo n se o f peripheral nerves to l o ad i n g . Jou r n a l o f Bone a n d J o i n t S u rgery, 8 1 A , 1 6 00-1 6 1 0 .

Headache in a mature athlete Gwendo/en Jull


Shirley was referred by a sports physician who she had consulted regarding her asthma. She was also suffering from almost daily frontal headaches. She has been having regular phy siotherapy on and orr ror the past year in conjunction with massage but had achieved no permanent relief. She had a motor vehicle accident (MVA) .35 years ago at which time she frac­ tured her thoracic spine. Although Shirley had some cervical stiffness. radiographs had shown only mild exit canal narrowing with no deterioration in the past 5 years. The sports physician believed that the stifr­ ness was contributing to her headaches. Shirley is a 54-year-old female who owns and works in her own retail business. She is also an ath­ lete who trains and competes in canoeing and has been successful at International Masters Games level. She had been training and competing in canoeing ror 15 years but in the last 2 years she has suffered from asthma and has had to ease of[ her training. The asthma is now under control and sl1e is starting to train again more seriously. This is more for her recre­ ational pursuits and desire for fitness rather than to compete at international level as her work commit­ ments and other newly acquired responsibilities pre­ clude her from dedicating the required time for this level of competition. Shirley reported that she had been suffering from headaches [or a long time and they certainly may have started before her MVA .3 5 years earlier. How­ ever. since the accident . she has always had troubles with her neck in some rorm. including wry neck

episodes and neck stiffness. as well as headaches. She reported that orten she can limit her wry neck episodes by concentrating on relaxation. but if the episode does not ease quickly. she consults a physiotherapist and attains relief. She also injured her vocal chords in the car accident. resulting in a hoarseness in her speech. Her new responsibilities include quite a deal of public speaking and ror the past 6 months she has been consulting a speech pathologist to assist with these problems. Currently Shirley sufrers from almost daily headaches or variable intensity. Some are severe and she is unable to runction while they are in the intense phase. which can last for several hours. These severe headaches are not frequent and Shirley cou Id not give any particular pattern that related to their occur­ rence. The moderately intense headaches are the more frequent ones. They last ror variable times from a rew hours to the whole day depending on how well she can intervene with either medication or attempts at relaxation or neck exercise. Shirley felt that she surrered only one rorm of headache and that all headaches were the same. except ror the intensity. The headaches are right sided. unilateral and in the frontal. retro-orbital area. The neck pain is less specific and is more a feeling of general neck pain and stiffness. There was no pain or discomfort reported in the rest of the race. upper limbs. thoracic or low back area. The headaches. whether moderate or severe. are consistently on the right side and do not change sides within or between headache episodes.

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With the intense headaches Shirl ey reported that

Shirley rep orted that she tries to control and relieve

she was often nauseous and occasional ly vomited but

the headaches with s imp le an algesics or aspirin and

had no other as sociated symptoms when headaches

neck exercises (s tretching ) with variable success.


were either intense or moderate She has never suf­ .

fered a p rodroma in association with any headache.

There was a family histo ry of headache in that her mother had suffered from migraine.

headache w as variable.

She has not attended for physiotherapy over the

Shirley reported that she could w ake with headache

last 6 mo nths but in the preceding 12 months she had

or tlI ey could come on during the day. The headaches would start in the front al region. They never started

been receiving physiotherap y for her headaches. The physio therapy which consisted of ma nual therapy

as neck pain, but a stiff. sore neck always accomp an

and muscle stretching exercises, gave some tempor­

The time of

onset of



ary rel ief but overall it had not had any permanent

ied her head aches. Shirley could not identify any particular provoca­ tive factors for her headaches or f a ctors that may pre


effect on her head ache condition. What she had noticed in the last 6 months was that her headaches

cipitate them. She could not pred ic t the onset of the

were a little less frequent and this she attributed to

severe headaches. Normally Shirley slep t on her side

returning to paddling , as weU as the postural advice

and used one normal sized pillow and one soft pillow.

and neck relaxation strategies taught to her by the

She consid ered that she was comfort a ble in bed and

speech pathologist

on the whole slep t well even though she could wake

Headaches were still suffered



speec b on


at le a st 3 or 4 days

with a headache. Her work involved a variety of activ­

per week. It would be unusual for her to go for more

ities and a variety of tasks and she had not noticed

than 2 d ays wi thout

that any particular task either specifically aggravated her neck or was likely to produce


headache She was .


headache of some so rt


Shirley related that what she wanted was some exercises or strategies that she could use to alleviate or at least help her to control her headaches.

usually quite physically active d uring tbe day.


• the temporal p a ttern of the headaches, namely datiy,

At the conclusion of the subjective examination, what was your primary hypotheSiS regarding the cuss the findings that you thought supported this

exercises • sidelocking

hypothesis? What were the features that you







(migraine not infrequently changes sides)

considered tended to n egate this hypothesis?

• reduce d frequency of headache with increased physical exercise in the past 6 months .

• Clinician's answer There were certain features that were consistent with a cervical spine cause or contribu tio n to the headache syndrome, while others were not suggestive of a cer­ vical musculoskeletal cause of headache, based o n a combinatio n of knowledge of the available research­ based evidence of headache presentations and classi


fications and my own personal clinical experience. The factors supportive of a cervical cause or com­ ponent to her headache were:

The factors that tended to negate a cervical cause or compo nent to her he adache were:

• the headache onset was in the frontal region rather than associated with neck pain or stiffness (it is common for migraines to start in the head with later spread to the neck , with the opposite app lying for cer vical headache)

• some headaches were of such severity to prohibit normal function (this is more


w ith

m igraine)

• an in itial history of trauma involVing an MVA, which the patient associated with a 35-year history of neck p roblems

with variable duration and intensity

• eas ing of headache with relax a tion of her neck and

source of the headaches? Could you please dis­

• provocative factors, especially mechanical factors involving he r neck, could not be identified

• a family history of migraine Copyrighted Material



• previous p hysi ot h erapy to her n e ck appe are d to

accompanied by muscle dysfunction. Previous tre a t­

assist the neck pain but not her headaches to any

ment had not specifically addressed any neuromuscu­

great extent.

lar dysfunction and the presence of this d y sfu nction could be a major contri b ut ing factor.


Considering the chronicity of the problem, did you at this stage consider the pain mechanism(s) that may have been mediating the patient's symptoms?

• Clinician's answer about the patient and her condition, hypothesizing about pain mechanisms was not a pr iori ty It was con­ .

sidered that more informed consideration could b e given to the proposed pain mechanisms once Imow­ ledge of the presence or not of symptomatic physical

impairments had been gained from the physical exam­ ination. The chronicity of the headache was not a con­ cern at this time. Many cervical and freque nt common

he ada ches h ave lengthy histories. The length

of history of cer v i cal headache does not preclude a peripheral nociceptive source amenable to manu al and other t herapies and has not necessarily been



tant factor in inlluencing treatment outcome in my past experience. The major aim at this time was to lTY to sort out if headache.



the patient suffered

The answer regarding initi al hypotheses


strates that the clinician is actively attempting to

At this stage. with the amount of information obtained


• Clinical reasoning commentary

from a cer vical

migraine or a mixed he adache form.

from the subj ective examination to

di ag n o stic hyp othesi s of cervical he a d a che This is .

typical of the pa ttern recognition process com­ monly used by experts. In particular. her knowledge

of the pattern of presentation of c ervical headache. partly based on skilled. reflective clinical reasoning and partly research based, en ables her to recognize the significa nce of clinical findings matchi ng (or supporti n g) elements of the clinical pattern she holds in her

memory Importantly the clinician has .


also recognized fmdings that are inconsistent with (or which negate) the cervical spine hypothesis and has kept her mind open to the possib i lity of

From the history, were there any factors that you maintenance of the headache problem? In particu­ lar, were there any psychosocial or stress factors?


migraine he a dac he or a mixtur e of the two. That is.

she has not ignored the clinical findings that do not lIt with the primary cervical headac h e hy pot hesi s and has thus avoided committing

thought may have contributed to the onset or


common rea­

soning error of being biased toward the favoure d hypothesis, particularly ifit is one usu a lly amenable to manual therapy. It is worth noting that so me potenti a l p athobio


l ogical mechanisms u nd e rlyi n g (and other fact ors contributing to) any cervical comp onent to the

• Clinician's answer There were no indicators at this time, or inde ed

match findings

elicited clinical patterns relating to her primary

headache have been hypothesized, as evide nced by


consideration of degenerative jOint processes and

that there were any psychosocial or adverse stress

neuromuscular impairment . It is implied that fur­

factors involved in the pathogenesis of this patient's

th er in formation obtained in the physica l examina­

headaches. From the history of neck pain dating back

tion will be used to test these hypotheses. a s well as

to the MVA. there was every likelihood based o n

th e source of the headaches.

ava i l able evidence that there would b e degenerative

In add i tio n the clinici a n h as made the judg­

changes in the upper cervical joints. The presence o f

m ent that there are no sig n i fican t psychosocial or

j o i n t pain and dysfunction would probably also be

stress factor s in the patient s presentation.






S i posture approached a n upright neutTal pos­

The basic shape of the postural curves was unremark­

ition. The shoulder girdles were sl i ghtly elevated.

able. with good head. neck. and thoracic alignment.

downwardly rotate d a nd p rotr a cted . The pectoral

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muscles were slightly hypertrophied and appeared

heightened activity palpable in the soil tissues: in the

tight. The bulk of the levator scapulae was evident.

anterior and middle scalene and sternocleidomastoid

The scalenes also appeared to be overactive. with full­

muscles bilaterally. Both first ribs were slightly elevated

ness in the supraclavicular fossae.

and hypomobile. Some slight tissue thickness was detected around the C2--C3 and C3--C4 zygapophyseal joints on the right side.

Active movements The patient was currently experiencing no pain.

Passive physiological intervertebral

Cervical spine movements were as follows:


• Ilex ion: full range of motion (ROM). no pain reported

There was a slight restriction in lateral Ilexion and

• extension: slightly restricted but with no pain. and

rotation bilaterally.

most notable at C2-C3

some hypomobility in the cervicothoracic region:

C3-C4. Some slight restriction in rotation

the pattern of return to neutral from extension

detected at CI-C2 bilaterally.

a nd



revealed a lack of control of upper cervical initi­

Anteroposterior glides

ation of the movement • rotation left and right: 75% ROM with a general feeling of stiffness. but no pain • lateral llexion left and right:

50% ROM with

scalene tightness restricting movement. but


reported pain • upper cervical flexion: full ROM. no pain • upper cervical extension: full ROM. no pain • CI-C2 rotation left and right: some general restric­ tion. but no reported pain. Thoracic spine movements were unremarkable and pain-free. Shoulder movements were full range and pain-free. with the pattern of control of the shoulder

A slight to moderate movement restriction was found on anteroposterior gliding of the C2-C3 and C3-C4 zygapophyseal joints on the right side. and to



degree on the left side.

Posterior palpation Time needed to be taken to achieve adequate relax­ ation of the neck. There was thickening 0[' the right C2-C3 and C3-C4 zygapophyseal joints.

Posteroanterior glides Local pain of moderate intenSity and muscle reactiv­

girdle revealing no obvious deficiency.

ity was provoked over the right C2-C3 and C3-C4 zygapophyseal joints. which were also moderately

Neural system

restricted to movement. These findings were evident

The Brachial Plexus Provocation Test (BPPT; Elvey. 1998) performed on the left and right sides demon­ strated no muscle resistance to gentle scapular depres­

to a lesser extent on the left side. The cervicothoracic junction




w as




sion. The completion of the tests was unremarkable and produced no pain other than a cubital fossa stretch. Opper cervicaillexion was not restricted. and the quality of the passive upper cervical flexion move­ ment was unchanged when the left or right upper limb was prepositioned in the BPPT position and when the left or right leg was prepositioned in


straight leg

raise position.

Tests of neuromuscular control The pattern of activation and holding capacity of the scapular synergists is tested by active repositioning 01' the scapulae onto the chest wall in the prone lying position (scapular retraction. depression and upward rotation).

w it h

no arm loading. Shirley's performance

was fair. with some unwanted contribution from latissimus dorsi. rhomboids. and levator scapulae

Manual examination

muscles. There were signs of fatigue after five repeti­ tions. The performance on the right side was slightly

Anterior palpation

inferior to that on the left side.

A poor ability to relax was noted. Anterior palpa­

The pattern of activation of the neck Oexors and

tion of the discs was unremarkable. There was some

holding capacity of the deep neck Oexors is tested

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with the patient in s u p ine ly ing. with the head and

and muscle reaction h ad decreased to a m i n o r level.

neck in

neutral position. Slow and controlled upper

a nd the j oint motion restriction had slightly reduced.

cervi cal Ilexion is performed to target incremental

There was n o change in the ROM of active cervical

pres s u re levels. w i t h the pres s u re sen sor inserted

la teraillex ion.


behind the neck and preinllated to 20 mmHg. Shirley's performance was poor. There was excessive recruit­ men t of the su perf icia l neck l1exors. as well a s visible recru itment of the p l a tysma muscle. She could not control


steady pressure reading beyond 22 mmHg.

Provisional diagnosis Shirley was likely to have a mixed headache form.

and even at this level she s howed ev idence of fatigue

with a c o m b i n a tion of migraine and

after three repetiti o n s.

ponent. Co nversely. the musculo skeletal dy sfun ction


cervical com­

may have been underly ing the compl a int of neck s t i ff­ ness and neck disco mfort but not the headache. PhYSical examination s ugges ted right C2-C3 and


C3-C4 zygapophyseal j oint a rthropathy (segmental

During posteroan terior gliding of the right C2-C3

degenerative condition) and poor neuromotor control.

and C3-C4 zyga pophyseal j oints. the provoked pain

especi ally i nvolving neck Ilexor synergy.



Prior to examining the mobility of the neural

neuromuscular examination and what is your

system. were there any possible indications

interpretation of the reassessment findings?

suggesting that this may have been a potential factor contributing to the symptoms? If not. what was your reasoning for undertaking this testing?

• Clinician's


Tes ting the cervical flexo rs and scapu l a r retractors a nd depressors has the side benefit of inducing reciprocal relaxation of the cervical extensor m u scles. i ncluding

• Clinician's answer

the deep cerv ical extensors such as the segmental

There were no partic u l a r ind icators that mechano­

m u ltifidus. This allows the symptom atic jo i n t to be

sensitiv i ty of the neural sy stem was contribut i ng to

repalpated with pos teroa n terior glides. tem pora rily

the hea dache syndrome. The neural system was being

devoid of pro tective muscle gu arding. Pain provoked

screened [or a ny involvement to allow i t to be removed

and perceived motion are aga in evalu ated a nd com­

from further consideration. It is also my pra ctice to

pared with the o riginal a ssessment. The result gives

attempt to exclude any l i m i t a t i o n of upper cervical

some approxima te indicatio n as to how much of the

flexion c a u sed by mechanosensitivity of neural struc­ tures. beca use if thi s is present it can influence the cra n iocervical


mu scle



origi n ally

p rovoked joi nt p a i n


restriction of

motion is c a u sed by reactive muscle spa sm and how


much is [rom articu l a r chan ges . This can help to guide

positive findings . Cond ucting these muscle tes ts with­

trea tment a nd often gives a d irection for the bala nce

out due con sideration of any neural tis sue sensitiv ity

behveen the components of manual therapy and thera­

(if present) can result in an u nnecessary aggr avation

peutic exercise.

of headache.

The t herapeutic exercise is aimed towards improv­ i ng neuromotor control. thus reliev ing the j oint of


What led you to reassess joint signs

provocative strains. When joint cha nges are not pre­

(posteroanterior glides) following the

sent o r not marked, the amount o f m a n u a l therapy

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requ ired is often less or has more of a neurophysio­ log ical rationale than a mechanical one. In the case of

• Clinical reasoning commentary

this patient. the re-evaluation indicated that articular

The response regardi ng mechanosensitivity of the

changes were present. as the motion restriction was

neural system indicated that the BPPT was und er

perceived to reduce only slightly. However. as pain and

taken for three sep ar a te reasons:

provoked muscle reactivity had decreased substantially

• as a scanning strategy to rule out an unlikely


this gave a good progn ostic indication th a t decreasing adverse muscle forces could relieve the joint pain. This gave a ration al basis for. and indicated the poten­ tial value of. therapeutic exercise to retrain good neuromuscular control.


source ( neural structures) for the headaches • to enhance the validity of a subsequent impor­ tant clinical test used to evaluate the possible c ont ri bu tion

of neuromuscular impairment in

the precipitation and maintenance of any cervi­ cal component to the headache • as a precautionary procedure to eliminate the

In view of the patient's histor y of asthma, did you consider assessing the breathing

possibility of aggravating sensitized neural tis­


sues during the craniocervical l1exion muscle test and worsening the patient's headaches. Th i nking Simultaneously on several levels such .

• Clinician's answer This was discussed with the patient. The p a tient was well aware of her breathing patterns and control of air int a ke and exhalation. The speech pathologist and the patient were working on this aspect to improve her voice



indica ted in this response. is typical of expert clin­

and the patient was already

employing basal expansion breathing exercises as part of this management. as well as relaxation and postural control strategies An emphasis was placed .

in the treatment on relaxation of the sca lene muscles

ici a ns. The clinician is enhancing her efficiency and accuracy by maximizing the v a lue (or 'pay­ out ) gained from this test procedure. '

The decision to reassess joint signs (posteroante­ rior glides) illustrates how the information obtained from one test can be of use in refinin g hypotheses in several categories. and thus again demonstrates efficiency in thinking consistent with a maximizing principle [n this case. reassessment of poste roa nte­ .


especially in the re-education of the neck l1exors in the craniocervicall1exion action.

rior accessory movement following the cervical and scapular muscle testing provided information of value in the following hypothesis categories: source (cervical joint




Your provisional diagnosis appears to suggest

(neuromuscular impairment hypothesis). patho­

two alternative explanations for the patient's

biological mechanisms (mechanical versus neuro­

headache symptoms. What further information


would you require from the physical examination

(balance between j Oint versus muscular interven­




in order to be more confident in attributing at

tion or manual therapy versus exercise therapy ) and

least some of the headaches to musculoskeletal

prognosis In order to derive the maximal value from


one test response the clinician must undertake


re!1ective thinking both during and following each clinical encounter, so as to broaden and deepen the repertoire of maximizing prinCiples

• Clinician's answer I wou l d have been a little more confident if the man­ ual






although this in itself is not totally conclusive. I was prep are d to give


trial of treatment to help to clarify

the situation and to come to a more conclusive diag­ nosis. I was aware that prev iou s tTeatment had assisted

The c1inician's thoughts on



tria l of treatment

reinforce the notion that the treatment itself is often needed to establish the diagnosis/hypothesis m ore confidently when this hypothesis (source and/or contributing factors) is still provisional or tentative. Consequently. the trea tment and the subsequent reassessment of the patient's signs and symptoms

the neck pain but seemed not to make a substantial

are integral elements in testing the hypothesis as

impact on the headache symptoms.

part of the hypothetico-deduciive reasoning process.

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po s tu r al and deep supporting role of muscles that the exercises wou ld t arge t .

• Treatment plan Poor muscle function is likely to have had a predomi­ nant role in aggravating the C2-C3 and C3-C4 z ygapo physeal joints. This is s u ppo r t ed by the clin­ ical fi ndi ng that the rec ipro cal i n hi bition of the ex ten­ s o r muscles afforded by the tests of m uscle function led to a reduction in provo ked pain duri n g the ap pli ­ cation of p ost eroa nte ri or g lidin g . This i n dicates the need for an em ph a s is in treatment on neuromus­ cular re -educ a tion and man u al the rapy to the s y mp­ tomatic join ts. The cervicothoracic r eg i on may also need to be mobilized as a poten tial co n tri bu t or to the pr o ble m .

Explanation of treatment exp l a in e d to Shirley t h a t my i n it i a l tho u g h ts we re t hat she wa s p oss i b ly s u f feri n g from either a mixed h ead ache form. wi th a m i xt u re of migraine and ne ck headache. or th at she was e xp e r ie nci n g frequent common migraine and had a separate and unr el ated pr o blem in her neck. T r eatme n t was capable of influ­ enCi ng headac hes arising from the neck b u t was u n likel y to have any marked effect on a ge nuine migraine component to her h e a d ache. In l i g h t of t he poor response to previous p hysical treatment in rela­ tion to any real affect on her h eadac h es . a trial of treatment was su gge s ted with cri tical appraisal of the results. The poorest resu lt wou ld be that he r com­ plaints of neck sti ffness could be lessen ed but there would be no c h ange in her headac he pattern. with the best result being e l i m i n a tio n of her headaches. The patient agreed to this approach . involVing a real­ istic a p pra isal of treatment ef fects . Explan a ti on was given as to the importance of cor­ rect muscle control a nd func t i on for the protection o f jOiots. The rationale pr ovid ed w a s t hat i f t h e j oints r egain ed go od muscle support. this wo u ld relieve jo int s train and pain: hopefully th is would. in t u rn. allevi­ ate the he ada c hes. As Shi rl ey was a spor tsperson and used to high - l oad exercise. time was taken to explain that the form of e xerc ise that she would be tau ght was different from e x erc ises unde r taken for streng th . endu rance or fitness. The a pproach e mph asiz ed pre­ cision and control. and an a n al o g y of ski l l train ing was given. The different fu nctional roles of various musc les w as ex plai ned . with an emphasi s on the I

Exercises . Upper cervical flexion

To control unwanted activity in the s u pe rfic i al neck flexors. the patient was t aug h t the rest position o f the mandible and retaught the pattern of slow and co ntro l led upper cervical flexion wh i l e in supine lying. The e m p h asis was on control and prec ision . and the 22 mmHg mark was ta r ge ted o n th e pres­ sure sensor ( atte m p ts at any higher levels resulted in re cruitme n t of excessive supe rfi c ia l m uscle a ct i vity ) . S h i rl ey was t a u ght to palpate the an ter i or neck region and to perfo rm the movemen t witho u t fee l i n g te n s i o n develo pin g i n the supe r ficial muscles. She was to practise the mo ve m e n t and hold the position for 10 seco nds.

Scapula 'setting' exercise

T h e s capu l a 'setting' exercise was retaught to the patient in prone lying with correction of the action an d with e m phasis on preCisi o n and contro l . The focus was on ge n tl y pOSitioning the sc ap ula back and down onto the chest wall and h o ld i n g the p O S itio n . The previ ous u n wan ted use of latissimus dorsi was corrected and the activity o f th e lower trapezi u s was inspected and palpated. Shirley was taug ht the exe rcise on the right and left sides sep arat el y.

Postural exercise

The use of these muscles was incorporated in a pos­ tural exercise in si tt i n g. First. the assumption of ne u ­ tra l u pri g ht posture was t a u g ht with cor re cti o n from the pelvis to ach i eve a neutral upright pelvic p osi tio n with a no r m al l umbar lordosis. Shirley was then tau g h t to l ift her s c apu la ge n tl y to pOSition it bac k and do wn onto the chest wall. ri ght and then l e ft. a nd to hold the pO S i tio n . A submaximal effort was en cou r a ged . On reassessment. pa i n and muscl e reaction pro­ voked had decreased to minimal leve ls d u ri n g p o s­ te ro an te ri o r gl iding of the right C2-C3 and C3-C4 j oints. JOi n t motion restriction was still prese n t but reduced. Active cervical lateral flexion was u n cha n ged .

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poi n t of fatigue . or when she co ns i d ered that she

H ome programme S h i r l e y was given written instruc tions for a home pro­ gr a mme ('or the three retr a i n i n g tasks: uppe r cerv i ca l fl e x ion . t he scap u l ar exercise i n prone l y i ng . and the

pos t ural exerc i s e . The upper c e r v i c a l Ilex i o n a n d sc a pu l a r exercises were t o be p e rforme d twice per d a y


The a im was to ac h i e v e 10 repe ti t io n s of e ac h exer­

cise. holdi n g for 10 seco nds The i m p o r t a n c e of preci­ .

sion was emp h asi z ed and it was ex pl a ined that at the

cou ld not accurately con trol the exercise. she was to s to p r a ther t h a n rei n force a n incor r ect pa ttern . The postural exe r cise was to be p ra c t iced repeat­ ed ly during the d ay and cues to remind her to perform the action were discussed . These inclu d ed every t i m e she answered the t e le p hon e a n d a ny time she walked up stairs (both common activities in her d a i ly rou tine

a t wor k)




Your initi al managem ent in volved a detailed

exercise will ass i s t their c on d i ti o n a n d the pai n-rel iev­

expl anation of likel y diagnoses. recommended

ing bene l1ts of re-educating musc l e control . wi l l also

treatment an d rationale. and req uired patient

assist with compli a n ce . Sh irl ey was a spor tsper son


contribution. Could you please elaborate as to

and more used to h igh-load exercise. The the rapeu tic

why you cons idered this important!

exercise was di re c ted towa rd m u s c le control and enh a n cin g the active muscl e support of the jOi nts. It is skill learni n g and e mph as iz es low- load e x erci ses with

• C linician's answer

prec ision and control . As this was d i frere nt to her con­

I n fo r mi n g the p a t i e nt is an impor t a n t aspect of a ny

cept of exercising for strength . car eful exp l a nation

m a n agem e n t programme. The patient prese n t ed with

was co n s i d ere d i mportant for complia nce


e xpe c t ati on


from her referri ng doctor that tre at­

m ent of her n eck would al leviate her headache. I was u nsure after the in i ti a l examin ation how muc h of the

head ach e sy n d rome was cervica l in o ri gi n

• Clinical

reasoning commentary

It was

The impo r t a nce of collaborative c l i nic al rea soning

undesirab le for the patie n t to have u nrea l istic expect­

is emphasized by t hi s discou rse. Not only is effec­


ation s of treatment and I a lso n eed ed a re a li sti c and

tive communication n e eded to ensure that the

critical evaluation o f tre atment effects to assist i n d i f­

a ctive i n terventions

ferenti a l d i a g nosi s I also re q u ir e d of her

( exercise compliance). but the role o f the pa t ie n t in



a ppr a i s a l


more crit­

of t h e n a ture of her h ea d aches a nd

aggrava t i n g fa ctor s to hel p i n d i ffere nt ia l di a g nos i s .


r epo r t i ng

accu rately

performed appropriately the

behaviou r



head aches follOWing treatment and at o t h e r ti mes

In my expe r ience rrom seei n g patients with head a c he

is seen to be crucial in determining t he re lative

who h ave pre v ious ly received phy siotherapy or chiro­

contribu tion of the cerv ical spine. Therefore. the

prac tic management without any rel ief. one of the

patient: is somewha t responsible for both t he

pri mary re a sons for the l ack of s ucce s s is that the

a gement

headache is n o t origin a t i n g from cer v ica l spine

Consequently. it is i mpo r t a n t t h a t t h e patient does

d y s func tion



p ro bl e m





no t have inappropriate or u n realistic expectati ons


P a t i en t complian c e in the t herapeutic exercise

of the

c l i n ic i a n

and o f her


( a nd any o ther treatmen t) is obviously critical to its

rehabilitation proces s

pote nti al success. A fu ll expl a n a ti on as to how tile

required to ov e rc o me such problems .

• Treatment 2

F u rther treatment Further tre atmen t occu rred over seven sessio ns Each


r ole i n


a n d educatio n i s t h e tool

( 1 week later)

Re-eval uation


session i n vo l ved


re-evaluation of S h irley. further

treatment and a reassessment of her progress


S h irl e y reporte d that she had had heada ches on the 2

d ay s fol low i n g treatmen t . but for the l as t 5 d ays sh e

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h ad been without h ea d ache. T h is was


breal< fro m

her no r m a l p a tt er n . w h i c h s h e fo und pleasing. T h e neck

ac h i n g


s t i ffness

h ad


percepti bly

c h a n ged . On p hysic a l exa m i n a ti o n , l atera l i1exion to the left

and right was s t i l l restricted to approxi m a tely 5 0 % range w i t h scalene tigh tness e v ident. Pos teroanterior glid i n g o f the righ t C2-C3 a nd C 3 -C4 j o i n ts provoked less pain and muscle reac tion t h a n at the orig i n a l assessmen t . a l t h o u g h hypomo b i l i ty was s t i l l present i n the j O i n t s . During the upper cerv i c a l l1exion task, S hi rley could target a n d hold a t the level of 2 2 m mH g


but ac ti v i ty 0 1' t h e s u p e r fic i a l l1 exor musc les c o u l d b e observed w i t h a t temp t s at any h i g her levels. Correc tion was needed w i t h speed o f performa n c e . S c a p u l a r set­ ting in prone ly i n g

w as

performed w i t h o u t s ufficient

prec i s i o n and u s ed l a t iss i m u s d o rs i .

Treatment The p a t ter n of i n teraction o f t h e d ee p a n d superficial i1exo[ muscles was again retra i n e d . Electromyogra­ phy (EMG ) b i o feedback was used for t h i s . in ad d i t i o n to pressure biofeedback ( F i g . 9 . 1 ) . The EMG was placed o n the s ternocleid omastoid a n d a nterior sca­ lene musc les. a n d S h i rl ey ' s task was to progressively ta rge t 2 mmHg incre m e n ts in pressu re wh i l e preve n t­ i n g a u d i ble feedback

from t h e EMG b i o feedback

machine. which would i n d icate i ncre a s i n g s u pe r fic i a l

F ig. 9 . 1

The c r a n i ocervical fl e x i o n acti o n (the

a n a to m i c a l acti o n of the deep neck fl exo r m u scles) performed i n supine lyi ng. The p ress u re cuff m o n i tors the s l ight fl atte n i ng of the neck that occu rs w i th the acti o n . T h e pati e n t i s i n s tru cted t o perform the u p p e r cervical

muscle activi ty. A level of 2 4 mmHg w a s achieved . The scapular setting action in prone lyi n g was reta u g h t and prac t ised . Both the correct and i n cor­ rect actions were used to help S h i rley to iden tify the

flexion acti o n to p ro d u c e a n d hold i n c re m e n ta l i n c reases i n p ress u re . The p rese nce of i n a p p ro p r i ate s u pe rfi c i a l fl exor m u s c l e activity is m o n i tored u s i ng electromyography.

correct action. The sittin g postural exercise was c hecked ( t h e action was too stro n g ) a n d cor rected .

In addition . treatme n t invo l ved mo b i lization of the

pressure biofeedback for home use. The home pro­

r i g h t a nd l e ft C2-C 3 and C 3 -C4 jOints . using a combin­

gramme was r e i n force d . w i t h targets o f 2 2 a n d

ation o f anteroposterior glides and segmen tal l a teral

2 4 mmHg s e t .

i1ex ion mobilization . T he cervicothoracic spine an d first rib were also mobilized.

• Treatm ent 3

( 1 week later)


Re-evalu ation

Lateral flexion demo n s trated better q u a l ity move­

S h irley reported t h a t s h e was c o n tro l l i n g the neck

ment, althou g h the r a n ge was u n c h a n ge d . Postero­

p a i n with the exerc ises, a l th o u g h she s t i ll had occa­

anterior glides

sion a l neck p a i n . Notably, s h e had had no headaches







C 3 -C4 j o i n ts provoked l i ttle p a i n despite the pres­

in the past week.

ence of slight to moderate hypomo b i l i ty. Some tissue

Physical examination revealed that both left and

relaxation was perceived on p a lpation o f the scalene

right lateral flexion were sti U restricted to approxin1ately

muscles a n d fI rst rib a re a . S h i rl ey was loaned

half range. but s howed better qu aliLy of movement.


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Posteroanterior gl i d i n g o f the right C2-C 3 and C3-C4 j Oi n ts pr ovoked s l i g h t p a i n and mu scle reac­ tion, with reduced hy pomobili ty. Duri ng the upper cervicai llex ion task. Shirley could target and hold at the level of 2 4 mmHg. with a good qual ity of per­ formance evident. Scap u l a r setting in prone lyi ng was performed wel l and she could achieve 10 repetitions on each side hold i n g for 10 seco n d s .

Treatment In retra i ning the upper cer v i c a l flex ion action. use was again made of EMG and pressure b i o feedback, with the target o f 26 mmHg be i ng a c h ieved. A new k i n aesthetic task was in troduce d , i n vo lv i n g randomly targe t i n g pressu res between 22 and 2 6 mmHg w i th

Fig. 9.2

Cervical ra nge of m ovement exercises i n to

rotation m a i n ta i n i ng the prone l y i ng on el bows position w i th scap u l a contro l .

precis i o n . Scap u l a r setti ng retra i n i n g progressed to a posi­ tion invo l v i n g prone ly i n g while supported on the

ti ght a fter paddl i n g . b u t she w a s a b l e t o ease it w i th the exercises.

elbows. Emphasis was placed on setting the scapulae

La tera l flexion both d irectio ns was now approxi­

and a ctivating the ser ratus anterior by drawing

ma tely 75% range. w i th an i n creas i n g lateral curve

the chest wall up to the scapulae and hold i n g the

evide n t . Posteroanterior g l i d i n g of the righ t C2-C3

positi o n . Two fur t her tasks were introduced i n this

a n d C3-C4 j oints provoked very li ttle d i scomfor t .

posi tio n : frrst. p a tterning o f the neck llexor synergy

although slight hy pomob ility persisted . D u ring the

through retrai ning the correct p attern of u pper cervi­

upper cervical l1exion ta s k . S h irley co u ld target and

cal and cervicai llex i o n /exten sion a n d , secondly, per­

hold at the level of 28 mmHg with a good q u a l i ty of

forming cervical rotati o n and lateral flexion ROM

performa nce. Similarly, sc a p u l ar setti ng i n prone lying

exe rcises wh i le m a i n ta i n i n g a neu tra l

( s u ppor ted o n the e l bows) was performed we l l .


ali g nme n t ( Fig . 9 . 2 ) . The C2-C3

and C3-C4 segments were again

mobi l i zed u s i n g anteroposterior glides and l ateral


flexion. but with more emphasis o n the right-sided

Upper cervical flex ion action retra i ning again made

j Oints. The cer vicothoracic re g i o n was also mob ilized.

use of EMG and pres s u re

biofeedback to target

28 mmHg. The kin aesthetic task to test the accu racy of targeti n g pressures b e tween 2 2 a nd 28 mmHg

Reassessment Latera l flex ion quality of movemen t improved . with slightly be tter ROM . No pain was provoked on pos­ tero anterior gl iding of the right C 2-C 3 and C 3-C4 j o ints. a lthough there was some residual hypomobility. The home programme was changed to inco rporate the progressions to the exercises.


performed with the eyes open a n d closed. Scapu l ar setting retra i n i n g was rev iewed . w i t h i n s tructions g i v e n t o continue at the same levels, both i n the prone ly i n g a n d prone ly i n g o n elbows posi tio n s . Mo b i l ization of t h e C 2 - C 3 and C3-C4 segments was repe ated . mov i n g gen tly but more fi rmly to the end of ava i l able range. The cervicoth oracic reg ion

• T reatment



weeks later )

was aga i n mobi l i z e d . with no table i m provement in tissue q u ality and movement of the fi rst rib are a .

Re-evaluati on Sh irley


The home progra mme w a s ch anged to i ncorporate that





head aches in the p a s t fo r t n i g h t but was able to control

these progressions


the exercises.

I n add ition ,

Shir ley was to start using the press u re b iofeedb ack a s

them u s i n g the exercises. For one episode she h a d

a checking d e v i c e . r a ther t h a n as a tra i n i n g device. i n

requ ired a n a l gesic tablets. Her n e c k became a little

preparation for remov ing t h e aid .

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Active l ateral Ilex i o n was a g a i n u n c h a nged , b u t there was now s l i g h t d i scomfo r t on posteroan terior

No reassessment was performed .

• Treatment 5 (4

gl i d i n g o f the ri g h t C2-C3 and C 3 -C 4 j o i nts, along with the persiste n t minor hy pomobility. In fac t , the whole neck reg i o n was a l i t t l e less relaxed. The upper

weeks later)

cervical flexion task demonstrated a goo d q u a l i ty of

Re-eval uation

performa nce (could target and h o l d a t the level of

S hi r l ey repor ted t h a t her nec k h a d been good and she

28 mmHg) , a s did the exercises i n prone lyin g sup­

had had no headaches . S he had been doing exe rcises

por ted o n the e l b ows.

and they were now p a r t o f her ro u ti n e . She was a lso wo rk i n g q u i te h a rd w i t h her p ad d l i n g tra i n i n g. Lateral

flex ion

uncha nged .


Pos tero a n terior

bot h







Treatm ent All the retra i n i n g exerc ises for mu scle perfo r m a nce

C 2-C 3 and C 3 -C4 j o i n ts was now p a i n - free. a l though


slight hypo mobility persisted . With the u pper cervical

M o b i l ization of the C 2 --C 3 and C 3 -C4 segments was

c hecked





good .

flexion task. S h i rley cou l d ta rge t a n d h o l d ( fo r 10 sec­

repeated, addres s i n g the hy pomo b i l i ty and s l ig h t

onds) a t the level o f 2 8 m m H g , w i t h a good q u a l i ty of

d i scomfo r t .

performance over the 10 repeti t io n s . T h e exercises

A m a i n tenance h o m e prog r a m m e w a s estab l ished .

performed i n prone ly i n g su ppor ted o n the el bows

Form a l exercises were to be performed once per day

were a lso performed wel l .

and postural exercises had been routi n e ly incorp­ orated i n d a i ly activity. T h e review was p l a n ned in 6 week s .

Treatment All retra i n i n g of muscle performance was performed

without the assistance of the b i o feedback devices.



weeks later)

Mob ilization o [ the C2-C3 and C 3 -C4 segments was

S h i rley telephoned to say she had to go i n terstate o n

repeated addressing the hy pomob i l i ty a n d preposi­

b u s i ness a n d was u n able t o attend for the review. She

tioning the j o i n ts i n to lateral flex i o n . Mob i l ization o f

repor ted she had been feel i n g good and was perform­

the cervicothoracic region w a s a lso repeated .

ing the exercises.

No fo rmal reassessment was u nder taken . The

A letter was written to the refer r i n g d o c to r.

home prog r a m me was a d a p ted to emphasize self­ mon i tor i n g strategies. The plan was [or o n e more treatment to assess the performance of the' exercises, a n d then u nder t ake a review.

• Treatm ent 7 (4

m onths later)

S h i r ley repor ted that she had been very wel l for about 3 months a n d so s h e then started easing o ff the exer­

cises. Over the last 2 to 3 weeks the headaches h a d

• Treatment 6 (3

star ted to retu r n . She had stepped u p h e r exercises

weeks later)

and they were helping a ga i n , but s h e fel t that t hey


were n o t as effective as before a n d she w i s hed to h ave

S h i r l ey reported t h a t h er neck had been goo d , a n d she

them checked aga i n .

had experienced one mild headache, which she could control with the exercises . However, 2 days e a rlier she had awoken with a severe headache and vom i tin g .

Re-evaluati on

S he h a d tried t o re l ieve i t w i th exerc ise b u t w a s u n able

T here was sti l l some general reduction i n ROM o f

to do so, a nd so took some medication before i t even­

rotation a n d l ateral Ilexi o n active movements, b u t t h e

tua l ly settled . She reported that she sti l l fel t a l i ttle

movement range h a d been retained. T h e right-sided

tight i n her neck b u t the experience had made her

C 3 -C4 joint was sli g htly p a i n fu l to poste r o a n terior

rea lise that s he was pro b a bly s u ffering from two d i f­

glides b u t C2-C 3 was asymptomatic. The j O i n ts had

feren t forms of head aches.

n o t regressed to any Sign i fic a n t exte n t , with only

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s l i g ht res i d u a l hypomo b i l i ty persisting. The hold i ng a b i l ity d ur i n g the upper cervic a l ilex i o n task had decreased sligh tly at the ta rget level of 2 4-2 6 m mH g. She was also performing the exercise with too much

• Treatm e n t 8 ( 2 weeks l ate r) Re-eval uation S h ir ley repor ted o n ly havi n g h a d one headache i n the

speed . The scapular setting in prone ly i ng exe rcise

l ast fo rtnight. She was padd l i n g regu larly with no i l l

was s t i l l performed wel l .

effects . She h a d b e e n d o i ng the exercises routi nely and fe l t s h e ag a i n h a d t h em u n der con tro l . T h e ri ght C 2-C 3 and C3-C4 j O i n ts were asymptom­

Tre at m e n t

atic but with residu a l sligh t hypo mobility. The sterno­

A l l exerc ises i n t h e trai n i n g regimen were reviewed

cle i d o m a s toid

and cor rected . S h irley elected to a c q u ire her own

rela xed . She had re gai ned her holding abi l ity during

pressure b i o feedb ack device for home use as it gave

the u pper cervical !1exion task and could ta rget a n d

her feedback on performance a n d an incen tive c hec k .

ho l d 2 8 m m Hg. T h e scapu l a r gi rd l e exercises were

M o b i lization o f

bei ng pe rfor med we l l .

t he C2-C3


particu l a rly


C 3 -C4 segmen ts was performed . a n d the cer v i c o ­ t h oracic re g i o n was chec ked . Self- m a i n tenance was restressed a nd S h i rley reported s h e now h a d






q u ite

T h e seU'-care prog ramme was fu lly re v iewed and rewri tte n

for the p a t i e n t .

S h i rl ey w a s forma lly d i scharged fro m treatmen t


u n d e rsta n d i n g of the effect of the self- m a i n ten a nce

b u t i n for m e d s h e cou ld c a l l fo r


was nece ssary.


review if she fe lt it

REASO N I N G DISCUSSION A N D C L I N ICAL REASON I N G C O M M E N TA RY The i m p rove m e n t of n e u ro m u s c u l a r con trol of

ev idence (Beeton and J u l l 1 9 9 4 ; Jull et a l . . 1 9 9 9 ; J u l l

key m u s c l e gro u p s appears to be a p r i m a r y goa l

et aI . , 2 0 0 2 ) .


of you r m a n age m e n t. What were the reasons that l e d yo u to th i s treatm e n t dec i s i o n ?


A t t h e early stages i n the patient's management,

Fo r exa m p l e , d i d you recognize a fam i l i a r patte rn

did yo u fo r m u l ate a p rogn OS i s ? What factors did

of presentati o n that you knew ofte n res p o n d e d

you weigh i n c o m i ng to this d e c i s i o n ?

favo u rably to t h i s i n terve nti o n ? O r d i d y o u base yo u r d e c i s i o n on research evi d e n c e ?

• C l i n ician's answer At the early stage, I was not prepared to olTer a prog­

• C l i n ician's an swer

nosis. There was some improvement i n j o int signs and

J o i n t pain a n d dysfu nction w i l l always be accompan­

mus cle fu ncti o n . b u t not e n o ug h to relate this con­

ied by muscle dysfu n ction. whether i t i s a spi n a l or

clus ively

ex trem ity j o i n t problem. The assessment of S hirley 's

Headaches. as with many other pa i n s . ca n i mprove by

m u s c le system revea led very poor muscle control. The

virtue of the fa ct that the s u fferer has sought and



improvement in the headaches.

n a t u re and extent of this i mpai rment directed the

been offered an i n terventio n . A ny prognOSis i n th is

n a tu re and prescrip tion of the exercise programme.

case wo u ld be more valid a t a l a ter s t a ge when i t could

T here was also knowledge ga i ned from previous treat­

be assessed whether progress was maintained over

ment that manual therapy alone. while giv i n g rel ief,

time and if sy mptomatic i mproveme n t was in line

did not address the neck dysfu nction in the long term .

with improvement in p hysic a l signs o f cerv ica l j O i n t

Resea rch i n to cervical headache has identified t h is

a n d muscle dysfunction .

pattern of m u scle dysfu nction and evide nce is emer­ g i n g of the e fficacy o f re-ed ucati o n of the m u scle dys­


Is there a reas on why you decided not to

fu n ctio n in the management of cervical he adache.

reassess after treatm ent 4 a n d also afte r s o m e

Therefore. t h i s approach wa s a lso b ased on researc h

late r treatm ents ?

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• Cl inician's answer

evidence as to

the clinical efll c acy of this i n tervcn­

Reassessme n t of segmenta l j O i n t hy pomob i l i ty, as one n . However, i t is al s o c lear that th ere were i n d i ­

o f the maj n outcomes o f manual tre atment. was being

vidual clinical Ilndings from the e x a m i n a t i o n of

i ncorporated i n t h e tTeatment. There was no ex pect­

t h i s patient

ation at this stage that l a tera l l1ex ion wou ld c h a n ge

the treatment i n this p a r t i c u l a r case. That i s , the

dra matical ly and it was not a primary outcome. ance of the exercise as i t was being ta u ght Its i m m e­ .


appropriateness o f

c l i n ician did not adopt a re c i pe - l i ke approach' b u t '

The muscle system was evalu ated by the perform­ d i a te effect on j o i nts was e v a l u a ted

that i n d i c a te d the

ma n u al

t h er a py la l lowed the exerc ise. There was no percei ved need to h ave a ny other re assessment at this stage.

instead adapted a pa r t i c u l a r t rea t m e n t

a pp r o a c h

to a n i ndiv i d u a l patient presentatio n .

The i m porta n c e o f reassessment i n the testi n g and reformu l a t i n g of hyp o t he ses is evident in the responses to the que s t i on s . A lthough at ti me s n o formal reasses sment h a s been u ndertake n , the

c l i n i c i a n is co n s t a n t ly i n terpreting the stream of

• Clin ica l

information that becomes avai l able d u r i n g the

reasoning commentary

This i n fo r m a tion l a rgely gu i d e s decisions related to hypo th e s e s in the cate­ gories of t re a t me nt ( i n c l ud i n g the need fo r pro­ appl ic a tio n o f t reatment.

The c l i n ician's t ho ughts suggest that the treatment decision to implement s p e c i llc n e u r o musc u lar exer­

cises was i n flue n c ed by k no w l ed ge ga i n ed from both

g re s s i on or c h ange) and prognosis, as w el l as the

the clinical

source ( s ) ( s u ch as cervical j O in t s ) and factors con­

past clinical e xper i en c e ( r e c og n i ti on o f

t r i b u t in g ( fo r example, n eu r om us cu l a r i mpair­

presentation/ pattern together with as s o c i a te d usual res ponses



a nd


ment) t o t h e he a da c h e .



a milder ' n eck headach e ' b u t could rel ieve it with the

exercises. She was conscientious about the exercises S h irley presen ted w i th a c u t e h i p p a i n 9 m o n t h s later,

and there were not many




canoei n g trip. S h e reported that she was

d ays that s h e fa i l ed to do

doing well with her head aches and h a d probably o n ly

Exami n a t i o n a n d treatment were d i rected to her

experienced one or two severe m i g ra i ne headaches i n

h i p problem and, a t the end of this sessio n , her neck

the time si n ce h e r l a s t v i s i t . Very occ a s i o n a lly, s h e h a d

exercises were re v i e we d .

R E A S O N I N G D I S C U S S I O N A N D C L I N I CA L R E A S O N I N G CO M M E N TA RY Was there any feature about this case that at any

palpation is insu filcient alone to j ustify thera py, as these

time in the course of the management was not

are symptoms common to many headache forms. For

enti rely consistent with you r expectation s !

S h i rley, there was clear evidence of cervical articu lar

and musc le system impairment, which j u stilled a tTi a l of treatmen t . There c an be q u ite marked overlap

• Clinician's answer

between the symptoms of freq uent common migraine

There were really no unex pected features of this case. It

withou t a ura and cervical headache. As in this case,

is not u ncommon for a patient to presen t with


when a neck condition is presen t it is o ften not pos s i ble

headache syn drome that is not clear cut and easily clas­

to predkt the contribution of the cervical dysfunction


I n such ca ses , it is necessary to have Ilrm evi­

to the head ache from a n in i ti al assessment. Therefore, a

dence of the presence of a pattern o f impairment in the

trial of treatment is necessary as par t of the diagnostic

cervical articular and musc u l ar systems in order to j us­

process. Although I was u n a ble to preruct the o u tcome

tify offering treatment directed at the neck dysfunction .

of treatment from the fIrst assessment, the outcome

The presence of some neck aching or tender ness on

was not unexpected but j ust the same very pleasing.

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• C l i n i cal

reason i n g co m m e n tary

associated w i th knowledge as t o t h e best o p t i o n s fo r

These thou ghts revea l that the c l i n ic a l pattern for

treatment and the l i kely responses to t hese i n t erven­

cerv i c a l headache recognized by the cl i n i c i a n was

t ion s ( progn osi s ) . This ind icates a

not j u st l i m i te d to diagnostic cues ( s i g n i fi c a n t c l i n i­

kn ow led ge base

h i g h ly developed

per t a i n i n g to headache presenta­

c a l I1 n d ings) and underlyi n g theoretical pathobio­

t i o n s and a n active effort on the part o f t h e c l i n i c i a n


t o c u ltivate t h i s knowledge through c l i n i c a l reflec­

mec h a n i sm s . The fact that the

c lin i c i a n w a s

n o t surprised at any stage of the ma nagement

process su ggests that the

c l i n ic a l

pattern was also

tion and by the rel a tin g of cl i n ic a l experience to

research evidence.

• Refe re n c e s Beeton. K . a n d J u l i o G . ( 1 9 9 4 ) . T he effecti veness of man i p u l ative

in the m a n a ge m e n t of headache: a si ngle case

p hys i o t h e rapy c c r v i c ogenic

b ra c h i a l

plexus t en s i o n . A u s l ra l i a n

Jou r n a l o r Phys iothera py. M o n o g r a p h 3 . 1 3- 1 7 . Julio

GA. B a rrett. C . . Magee. R . and Ho. P.

s t u dy. Phys i o t herapy. 80. 4 1 7-4 2 3 .

( 1 9 9 9 ) . Tow a r d s c l i nica l c h a racteris a ­

R . ( 1 9 9 8 ) . Com m e n ta ry : t reatmen t of a rm p a i n associ<l ted with a b n o r m a l


El vey.

of muscle dysfu nction i n c e r v i c a l hea d a che. Cepha l a l g i a . 1 9 . 1 7 9-1 8 5 .

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C . . Trol l . P . Po ller. H . ct a l . ( 2 0 0 2 ) . A r a n d o m i z ed c o n tro l l e d tri a l of exercise a n d m a n i p u lat ive therapy for cervicoge n i c hea dache. S p i n e .


2 7 . 1 8 3 5- 1 8 4 3 .

T h o rac i c pai n l i m iti n g a patient's sec retari al wo rk an d spo rt Dian e Lee


Ms Thomas ( Ju l ie) presen ted w i th p a i n i n three thor­

After 6 weeks , Ju lie returned to h e r physici a n w i t h

acic locations that h a d com menced after a motor

reports of o n g o i n g p a i n t h a t c o n t i n u e d t o l i m i t her

ve h i cle acc ident. Eighteen months previously, she

activities. Prior to th is accident, she was a n av id s now

was on her way h o me fro m work when the veh icle she

skier and a sailor but she had n o t been able to return

was r i d i n g in ( fro n t seat p assenger) was b roadsided by

to any level of acti v i ty that involved p u s h i n g o r

another, which ran a stop s i g n . The p O i n t of impact

p u l l i n g w i t h her a r m s . Anticinfl a m m a tory medica­

was just behind the passenger ' s d oo r. Ju l ie was

tion was prescribed and she was referre d for physio­

wea ring a three-po i n t se at belt that activated such

therapy. Julie received u l traso u n d , heat and massage .

that the force of the impact d rove her thorax i n to

from which she fe l t o n ly temporary re l ie f. When a ny

right rotation a n d flex i o n . She remembers fee l i n g an

exercises were prescribed , she fo u n d both the local

immed iate s h arp pain on the left side o f her m i d -back

mid-thoracic pain and the l a teral costa l pain were

(pain one) .

aggravated. Julie c o n tinued to





This p a i n was l oca lized l a teral to the spine a n d

secretary throughout this experience, althou g h she

med i a l t o the vertebral border of the left scapu l a . S h e

req u i red the use of a n a l gesic medication to complete

w a s ab l e t o g e t o u t of h e r vehicle, even tho u g h i t was

her d ay. The an ti-inll ammatory medic a t i o n began to

substantially d amaged by the i mpact. and im medi­

aggravate her stomach a fter 3 weeks a n d so she d i s ­

ately no ticed that certa i n movements.

continued t h e m . A m i ld s e n s e o f i n d i gestion persisted


bre a t h i n g . aggravated her p a i n .

even a fter the cessation o f medica tion ( p a i n three ) .

Later that eve n i n g . Julie ' s p a i n bega n to spread as a deep ache a n d reached the left l a teral a spect of the thora x .

With respect t o her feel i n g s

regardin g

the e ffect

this problem was h av i n g on her life and i ts m a n a ge­ ment to d a te, Julie conveyed her distress about the

E a c h fu l l breath w a s accompan ied b y a sharp

non-resolution of her sy mp toms and the lim itations

shooting pain that ran fro m T 6 beneath the left sixth

they had i mposed on her l i festyle. S h e expressed s o me

rib to the rib angle ( pa i n two ) . Julie was sen t for X-ray

concerns regard i n g ever b e i n g able to retu r n to the

sca n n i n g by her attend i n g p hysici a n and no osseous

leve l o f sports she h a d previou sly e nj oye d : however,

abnorma l i ties were fou n d . She was advised that this

she d i d n o t appear to be p a i n focussed or exaggerate

was a 'soft t i ssue mj ury ' and that s he would heal in

her compl a i n ts . and her concerns seemed to be very

time. Over the next few months the i n te n sity o f both

appropr i a te and realistic. Both her home and work

pain one a n d pain two s o ftened somewhat but never

environ ments were good with fa m i ly, co-workers a n d

d i s ap peared .

h e r emp loyer a ll bei n g suppor tive.

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1 49


Sy m ptom b e h av i o u r

When first see n , Julie 's pain was persisting i n i t s ori­ ginal location (pains one . two and three). Most move­ ments and/or sustained postures, particularly left rotation combined with extension of the thorax, aggravated the mid-thoracic and left lateral costal pains. Cervical movements on their own were not a problem. Julie felt that she had never been able to take a deep breath since the time of the impact. She was able to type for 1 0 minutes and to sit unsupported for

� J D

3 0 minutes. She frequently changed positions for relief. She woke often during the nig ht and her most comfortable place/position to sleep was semireclined in a chair. Screening with respect to possible precautions and contraindications to physiotherapy examination and treatment (e.g. general health. present and past medications, spinal cord . unexplained weight loss. cardiac/v isceral dysfunction, special investigations. etc. ) were all negative.


What were yo u r tho ughts at th i s stage ?

• C l i n ician's answer Possibly a mechanical dysfunction (joint shift or flX­ ation) had occurred during the impact and had not been cor rected nor spontaneously recovered. When an articular block is present. exercise tends to increase the local pain. When the problem is mechan­ ical . anti-inflammatory medication has l ittle long­ term effect since inflammation is not the primary source of nociception. Analgesic modalities do not affect the biomechanics of a blocked j Oint: therefore, any pain relief would only be temporary.

enjoys, this did not appear to be creating any dysfunc­ tional health beliefs or behaviours and I did not feel t hese emotions were going to interfere with her com­ mitment to recover y. I always include psychosocial considerations in the management of my patients since we treat human beings not j ust thei r body parts . I try to create a positive envi ronment with realistic expectations ( for both myself and the patient) so that treatment can be optimized . At th i s s tage of yo u r exa m i nation what were yo u r tho ughts regard i ng path o b i o l ogical pain mechanisms, s p e c i fi c a l l y did you fee l one m e c ha n i s m was d o m i nant! What c l u es i n the

With i n the hypoth e s i s catego ry 'activity a n d parti c i pation capab i l ities/restrictions', the pati e n t c l ea rly has a n u m b e r o f general fu n c t i o n a l l i m i tati o n s i n c l u d i ng diffi c u l ty b reat h i ng, typ i ng/ p ro l o nged s i tting, and any activity req u i r i n g pu s h i ng or p u l l i ng. In addition to th ese, we re there any psyc h o s o c i a l (e.g. cogn itive o r affe ctive) p ro b l e m s appare n t i n h e r p resentati o n ? C o u l d you b r i efly ex p l a i n wheth e r th ese were an i s s u e in th i s pati e n t's p resentation a n d if so

s u bjective exa m i nation have led you to th is i m p ress i o n ?

• C l i n i cian's an swe r The information supported my original impression that a j oint fixation was present. Her symptoms were aggravated by certain postures. thus implying a peripheral nociception and not a centrally mediated situation. The inability to lie down is common when a joint fixation exists in the thoracic spine.

h ow they i n fl uenced you r exa m i nation and m a n agem e n t.

With res pect to the hypothesis category of ' p recautions and contra i n d i cati o n s to exa m i n ­

• C l i n ician's an swer

ati o n a n d manage ment', cou l d you o u tl i n e t h e

I did not feel that Julie presented with a cognitive or affective problem. While she did convey a degree of distress and concern regarding her continued symp­ toms and inability to return to the activities she

key features at t h i s p o i n t that g u i ded yo u r p l a n s regard i ng extent of exa m i nation a n d choice o f treatm e n t. Specifi c a l l y we re there a n y p recau ti o n s o r c o n tra i n d i cati o n s ?

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• C l i n i cian's an swe r

• C l i n i cal

There were no contraindications that I i de n t i fied from the subj ective exam ination . Precau tions are i mport­ a n t and whenever there is a l a te nt na ture to the symp­ toms or a sense of neural i nvol ve m e n t (lateral refer ra l of p a i n as we l l as poten t i a l neural mediated v i scera l symptoms) the ex a m i nation of the motions that stress the neura l system sh o u l d be approached w i th care. In other wo rds . no fo rcefu l movements a re used and symptom respon ses are mon i t o red with more time given fo r onset.

reason i n g commentary

Even in t.he opening moments


t he


encounter. it is clear that the clinician is already beginning to formulate her thoughts on a broad range of hypotheses. with consideration given to t he patient's activity/participation restrictions

(i.e. phys­

ical limitations in breathing and activities i nvolving push ing and pulling. as well as inability to resume skiing or sailing. with no psychosocial impairment apparent at this stage ) . dominant pain mechan isms (Le. no c icep t i ve). source of the pain (Le. local tho­ racic tissues), contributing fa ctors (e.g. motor vehicle


What were the range of hy potheses yo u we re c o n s i d e r i n g h e re for possi b l e s o u rces to each of the th i s lady's sy mpto m s ? Can yo u briefly i n d i cate of these what yo u c o n s i d e red most l i kely and why ?

accident. exercises) and prognosis (Le. not impeded by patien t s cognitive or affective status). '

Not all joint res triction s or fix a tions will be p a inful or stay painfu l . The neurological expl a nation for why some do and others do not must relate back to the extent of fixat.ion t.hat exists and the contribution of the other co n t ributin g physical, environmental.

• C l i n ician's answe r

processing and output mechanisms. which combine

At this point. I felt the symptoms were cOmi n g from

to form each patient's u n ique presentation. Th is

local tissues in the thorax rat he r than being referred

underscores the importance of a holistic reasoning

from the cervical spi ne since it was moveme nts from

approach that is d iagnostic in both a pathobiological

the thorax and not the cervical spine that were a ggra­

a nd a narrative ( L e. seekin g to understand how the

vating. In additi o n . the qual ity of pain ( s h arp and fairly

problem has impacted on the pa t ient

loca l ized with i n the thorax and consistently agg ra­

clinician ' s consideration of psychosocial fac to r s in

vated by certain movements) was sugges tive of a local

her assessment of patients problems highlights her

sou rce and not a referred one. I be lieve consistency,

attention to this key area of reasoning and to her

reproducibi l i ty


focussed location are qual i ti es of a

local source as opposed to


caused me to foc u s on her thorax was her breathing

s life) sense. The


patien ts' unique pain experiences.

referred source of pain .

A key p o i n t i n t h e subjective examin ation that


For Julie, the clinician has highlighted feature suppor tin g




nociceptive domi nant pai n

mechan ism . that i s the clear stimulus-response

comp l a i n ts . This i s comm o n when the biomec hanics

rel ationship between the patient's posture and her

of th e r i b s

a ffected and rare ly seen when thoracic

symptoms. a relationship also seen with the other

pain is refer red fro m the cervical spine. While i t i s not

aggravating activities . Long-term problems such as


possible to specify precisely which tissues are i nvolved

this often have or develop abnormal centra l nerv­

b ased o n information fro m the s u bj ect ive exa m i n ­

ous system processing. However. when the sup­

a t i o n al one, m y experience w i t h similar presen tations

porting evidence of a nociceptive pain mechanism

s uggests pain one was likely to be from a left zygapophy­

pattern i s combined with the negating evidence of

seal j o i n t or costotransverse j O i n t in the mid-thoracic


region (T3-T S ) . Pain two could also be from these

nociceptive dominant pain mechanism hypothesis

a pp

are nt healthy psychosocial presentation . the

local somatic structures or quite possibly a neuro­

i s l og ical give n the information avai lable at this

genic p a i n from an interco stal nerve on the left in the

stage. This is

m id-thoracic regio n , an impression supported by the

ties to access quite spec ific patterns of clinical pres­

shooting n a ture of that pain . Pain three, the mild indi­

entation. which is

gestion . was l ikely a direct result of a n ti-inl1ammatory

clinical ex peri e nc e (Le. pattern recogn iti on ) . It also

intolerance but could also h ave been a referred symp­

illustrates the expert's ability to think on multiple

tom med i a ted by the sympathetic nervous system in

levels: in this case considering multiple hypotheses

the mid -thoracic spine.

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nice clear example of experts' abili­


built up from years of reflective


simult aneously and then refining them i n Ught of fur­

light of t h e physical prese n tation t h a t emerges .

ther information (Le. hypothetico-deductive reason­ ing ) . As with all hypotheses though . and p o i n ted out

Simila rly. the response

to the ongoing man agement will fu rther support or negate this hypothesis and. in

by the clinician here. this represents only an initial

turn . contri bute to t he evolving understa nding of the

i m pression and wil l have to be considered further in

prob l e m a nd r eco gn i t i o n


of management req uired .


Po stu t"e On ex a mi n a t i o n of the spinal

curves . hypertonic i ty o f the erec tor spinae muscle wa s n ote d bila te r a l ly in the mid-thoracic region . This i ncreased activ ity was not segmental and tended to hold the mid-thorax extended rel ative to the c ervico t ho r acic ( C 7-T 3 region) a nd thoracolumbar r e g io n s ( T 1 1-L l ) of the s p ine. J u l ie's breathing pa ttern wa s s h al l ow a nd a p i c al .

F u n ct i o n al m ove m e n t and positional tests

B o t h the l e ft and right costo t r a n sverse j O i n ts ( s ixth rib a n d T6 ) we r e able to gl ide superiorly and i n feriorly. alth o u g h aga i n more forc e was requ i r e d to ach ie ve

fu ll motion.

Horizontal translation (T5 a n d left and right sixth ri b s rel ative to T6) was ma rke d ly bloc ked fo r right lat­ eral tr a n s l a t i on of T5 and tbe s i x t h ri bs rela tive to T 6 . with a bard end-feel t o t h is motion ( r i g . 1 0 . 1 ) . Le ft l a teral tra ns l a t i o n was l i mited co mp a re d with the seg­ ment above a n d below. with a softer en d-fee l th a n that o f rig ht lateral tra nslation ( r i g . 1 0 . 2 ) .

Wh e n Julie was exa m i n e d . all movements of the mi d ­ th orax were l imited and a ' kink' i n the s p i n a l c u r ve was apparent a t the s i x th th o ra cic r i n g (T 5-T 6 and le ft a nd r i g h t s ixth r i b s ) . This k i n k was mos t apparent i n both right a nd l e ft rotatio n . On positional testi n g . T 5 w a s r i g h t rotated relative t o T6. The left s i x t h r i b was posterolateral re lati ve to t h e seve n t h a nd the ri g h t s i x t h rib w a s ante r ome d i a l relative to the s e v ­ enth. T hese fi nd i n gs did n o t c h a n ge w h e n positio n a l a n a lysis was done i n nex i o n . neutral or extens ion o f the mid -thorax.

Passive p hys i o l ogical m o b i l ity tests (osteoki n e m atic fu nction) A l l mo t i o n s

(nexion, ex te ns i o n , left ro t a tio n right .

rota t i o n . left s ide nexion and right side l1ex ion) were limited with an end -feel of reactive muscle spasm.

r es tr i c te d i n all directions ( nex io n extensio n , left rotati o n , right rota­ tio n . left lateral ben d ing and r ight l a teral bending) when c ompa r e d with the levels above a nd bel ow.

The pas sive mobility at T 5-T6 was

F ig. 1 0 . 1

The b i o m e c h a n i cs proposed to o cc u r i n the

m i d-thorax d u ring right rotation of the trunk. ( R e p ro d u ced by kind permission of D e l ta O rthopaedic PhYSiotherapy C l i n i c . from Lee 1 994b.)


Passi ve stab i l i ty tests of at"th t"O ki netic fu nction

ex a m i n at i o n a l l t e s t s were n o r m a l for at T 5 -T 6 , be tween T6

Passive accessot"y m o b i l i ty tests

On the first

(at"t h t"O k i n e m atic fu n ction)

segmen ta l ar ti c u l a r st a b i lity

left a n d ri g h t zygapo physeal j oi n ts (T5-T6) were a b l e to g l i d e s u pe r i o r ly a n d i n feriorly, a l th o u g h more force was required to a c h i eve fu ll moti o n .

B o t h the


and sixth ribs a n d between t h e s i x t h r i b s and sternum 1 0 . 3 ) . Th e s e tests incl uded :

(Fig. •

ver tical (co mpressi o n . tracti o n )

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Fig. 1 0 . 2

At the l i m i t of l eft l a teral trans l a t i o n , the

superior vertebra side fl exes to the right a l o ng the p l a n e of t h e p s e u d o 'U' j o i n t fo rmed by the i n te rve rtebral d i s c and the s u pe r i o r costove rtebral j o i n ts . ( Re p ro d u ced b y k i n d p e r m i s s i o n o f D e l ta O rthopaed i c Phys iothe rapy C l i n i c , from Lee 1 994b.)

• a n teropos terior. postero a n terior t ra n s l a tion T 5-T 6 • tra ns verse rotation left a n d right T 5 -T o

F i g. 1 0. 3

P a s s i v e t e s t fo r r i g h t h o rizonta l tra n s l ation

• a n terior tra n s l a t i o n T 6 /s i x t h ribs left a nd rig h t

s ta b i l i ty ofTS and the l eft and right s i xth ribs relative to

• a n teroposterior costoc h o n d r a l j o i n ts , sternochon­

T 6 . T h e pat i e n t s i ts , arms crossed to oppos i te s h o u l d e r s ,

dral j o i n ts

a n d the t h e r a p i s t s ta n d s bes i d e the pati e n t. W i th the right

• horizontal tra n s l a t i o n l e ft a n d right T 5 and s i x t h

han d/a r m , t h e t h e r a p i s t pal pates the thorax such that the fifth fi nge r of the right hand l i es a l o ng the l eft s i xth r i b .

ribs/T 6 .

The transverse p rocesses ofT6 a re fixed with the l eft hand . A p u re right ho rizontal tra n s l ation fo rce i s a p p l i ed to

M uscle function tests

the t h o rax through the l eft s ixth rib. This w i l l tra n s l ate

G i ve n t h e m arked a r ti c u l a r fi nd i n g s . a complete m u sc le ba lance a n a lysis for s p i n a l stabi lization a n d

the s ixth r i bs and TS to the right relative to T 6 . N ote the q u a n ti ty of motion a n d i n parti c u l a r the e n d fee l of motio n . ( R e p rod uced by kind permission of

sc a p u l a r control was n o t d o ne on the fi r s t exami­

D e l ta O rth opaedic Phys i o t h e rapy C l i n i c , from Lee

natio n .

1 994b . )

Neural function tests Conduction a n d m o b i l i ty were assessed.

Mobi l i ty . The fu ll slump p o s i t i o n aggrav a ted t h e l e ft

Conduction. All tests for u pper motor neuron con­ d uction

thro u g h the s p i n a l



lateral costal p a in and t h i s p a in c o u l d be s e n s i tized


(brougbt o n a n d re lieved) by vary i n g t b e positio n of

(Pla n ta r response tes t , clo n u s ) . The ski n beneath the

J u l i e s h e a d / neck when she was i n fu l l mid-thoracic

l e ft sixth rib was hyperse n s i tive to l i g h t touch a nd

11ex i o n . It right r o t a t i o n was ad d ed to the fu l l s l u m p


p i n prick laterally to the m i d - a x i l l a ry l i n e. There was

positio n , s he began to feel very u n we l l ( s l i g h t ly n a use­

no evidence of d ecreased motor i n nervation o f the

ated) a nd a sympa thetic res p o n se could be prec ipi­

left six th i n tercostal muscle.

tated i f this posi t i o n was sustained.

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Please d i sc u s s yo u r u s e of fu n c t i o n a l m ove m e n t and position tests, in particular you r interpretati o n o f a 'fixati o n ' .

• C l i n i c i an 's an swe r Fu nctio n a l movements tests eval u ate the qual ity o f movement. segme n ta l ly a n d collec t ively. d uring active range o f motion. The movements tested i n c l ude cardinal plane motion (pure sagittal . coronal and tra nsverse planes) or combined movements. Positio n a l tests are passive tests that i nvolve observa­ tion (looking) and palpation (feeling) of bones . We look for ma rked differences in the resting position of one bone relative to a c a rdin a l body plane as well a s relative t o one another. T hese tests help t o detect joint fi xations. With fixations we are t a Uei ng about a j Oint that i s held beyond i t s physi ological motion barrier and ye t within its anatomical motion barrier (it is not dis­ located ) . What holds it there? The j Oint becomes exces­ sive ly compressed by muscle forces . which d u ring the inj ury contract to prevent dislocation . Sometimes, like in the knee, an in tra-articular structure ( meniscus) can m a i n ta i n the j Oint fixation. More often, the posi­ tion is held by compression [ro m the muscles that cross the j o i n t . When a j oi n t is fIXated , the resting position of the bones d oes n o t c hange when i t is examined i n n.ex­ ion. neutral or hyperextension. By comparison. posi­ tio n a l c h a n ges that are the res ult of muscle imbalance frequen tly change from the extended to n.exion posi­ tion . thus the need to test in a ll three positio n s . Please e xp l a i n yo u r analys i s o f the p hysical fi n d i ngs and h ow they re late to you r choice of treatm e n t.

• C l i n i c i an 's answe r In order to ex pla i n the abnormal biomechan ics that have occurred here and , therefore. the c l i n ical rea­ soning behind the tre atment chosen . i t is necessary to u nd erstand what occurs normally in rotation of the mid-thorax. During right rotation of the mid-thorax (T 3-T8). the fol lowing biomech a n ics are thought to occur (Lee. 1 9 9 3 : 1 9 9 4 a . b ) . The superior ver tebra rotates to the right and trans lates to the left (see

Fig. 10 . 1 ) . Right rotation of the superior vertebral body 'pulls' the s uperior aspect of the head of the left rib forward at the costover tebral joint. i nducing anter­ ior rotation of the neck of the left rib (su perior glide at the left costotransverse j oi n t ) . and ' pushes ' the su pe­ rior aspect of the head of the right rib backwa rd . i n d ucing posterior rotation of the neck of the right rib (inferior glid e at the right costotran sverse joint) . The left l ateral translation of the superior vertebral body 'pushes' the left ri b posterola tera lly along the l i n e of the neck of the rib a nd causes a postero la teral trans­ lation o f the rib at the left costotransverse jOint. Simultaneously. the left latera l translation 'pulls' the right ri b anteromedially a long the line of the neck of the rib and causes an anteromed ial translation o f the rib at the right costotra nsverse joint. An a n tero­ medial/ posterolateral slide of the r ibs relative to the transverse processes to which they attach is thought to occu r during axi a l rota tion . When the l i m i t o f this horizonta l translation is reached. b o th t he costoverte­ bral and the costotransverse l igaments are tensed . S tability of the ribs both a n teriorly and posteriorly is requ ired for the following motion to occur. Further right rotation of the s uperior ver tebra occ u rs as the superior ver tebral body tilts to the r i g h t ( gl ides su per­ iorly along the left s uperior costoverte bral joint and inferiorly along the right superior costoverte bral joint). This tilt ca uses right side nexion o f the superior ver tebra a t the l i mit of righ t rotation of the mid­ tho racic segmen t (see Fig. 10 . 2 ) . I n Julie ' s case, the s ixth thoracic r i n g (T 5 -T 6 . the left and right sixth ribs and all of their related j o i n ts) was not able to tra nslate latera lly to the right. This dysfu nction i nvolved all fo ur bo nes of tbe sixth thor­ acic r i n g and was not j u st the consequence of a restriction of o ne zygapophyseal joint nor o ne costo­ tra nsverse j o i n t . The passive accessory mobility tests revealed full motion at the zygapophysea l jOints as well as the costotra nsverse j oi n ts. although a greater passive force was req u i red to produce the motion . This resistance to movement (as opposed to l ack of move­ ment) produced a kink in the mid-thoracic spinal cu rve during all of the fu nction al movement tests as well as i n the passive phYSiological mobility tests of the sixth ring. The marked block ( h igh resistance) to rig h t lateral transla tion o f the sixth ring preve nted

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the an teromed ia l translation of the l e ft six t h rib, re l a­ tive to the left tra nsverse process of T 6 , and the pos­ tero l a teral transl a tion o f the right sixth rib, rel ative to the right transverse process of T 6 , neces sary for left rotation o f T 5-T 6 and the s i x th ribs. During forced or sudden u ncontrol led rotation o f the mid-t horax. a segme ntal thoracic ring c a n become 'stuck' o r h e l d a t the limit of motio n . It is c u r­ rently th ough t that excessive compression of the articular surfaces occurs a t the moment of inj u ry, and th is compression m a i ntains the a l te red resting position. This compression i s the resu l t o f the central nervous system's response to t he sudden a fferent input i t is receiving from the defor m i n g a r ticu l a r structures. T h e central nervous system increases the segmental muscle ac tivity to preven t fur ther deform­ a tion o f the a r ticu l a r s tructures (Lee and Vleemi n g , 1 9 9 8 ) . This efferen t motor response is s u s t a i n e d by the distorted a ffere n t input from t he displ aced articu­ lar structu res . When the neura l tissue becomes sensi­ tized by the excessive central a fferent bombardment, fu rther lengthening of the system can provoke symp­ toms . This cou ld . in part. explain the positive slu mp test as wel l as the agg ravation of sympto ms with right rotati o n . A spontaneous efferent d ischa rge through the sympathetic system could be respo n s ible for the visceral symptom of nause a . Treatment, therefore, requires t h e normalization of the afferent input to the cen tra l nervous system such that the effere nt output to the segmental muscles ( a nd viscera) is red uced , the articu lar compression is relieved and the amplitu de of the j oint's neutral zone ( detec ted thro ugh passive accessory mobility testing of horizontal translation) is restored. In a biomechanical appro ach to treatment, this can be ach ieved through specific manu a l therapy followed by motor control re-ed ucation . With the p o o r re l i a b i l i ty of m a n u a l tech n i q ues to j u dge positional a l ign m e n t a n d m o b i l i ty, and the normal va riation a c ross the p o p u lati o n , h ow do you weight the s ignifi cance of yo u r m a n u a l exa m i nation fi n d i ngs i n reac h i ng a d i ag n o s i s a n d selecting a treatm e n t ?

• C l i n i cian's an swe r firmly believe ( b u t u n fortunately cannot prove) t h at when we test the i n ter-tester rel iability of a man­ ual techniq ue we often start by asking the wro n g


questio n . If t h e question is inappropriate, then the answer is not u sefu l . For exanlple, If we ask, 'How much is this jOint movin g? ' , we h ave to apply a stan ­ dard of what w e think is norma l . In other words. is this j oint mov ing more. less or the same as we think it should . As you mentioned , there is a wide variation of movement possibilities across the popu lation and, therefore, a n accu rate answer to this question is impos­ sib le because ' norma l ' is a moving sta ndard . What a re we reaUy comparing the motion with? Even if we ask the questio n . 'Do I feel the same amo unt of movemen t as the next tester? ' , I must apply a scale of motion ( L e. norma l, sti ff. hypermobile) to categorize wha t I am feel­ ing. Where does the standard come from? Someone who writes a book saying each segmen t should h ave so many degrees o f motion? Where d oes this information come from and, given the wide variation of ' n orma l ' , how can one number be adequate? When we i nterpret what we are feeling i n terms of amount of movement, there will be less consistency between testers. Instead . we need to evaluate motion within the same individual by comparing motion to levels above and below and on the left and right sides . Instead of emphaSiz i ng the quanti ty of motion (Le. stiff or l oose) , whic h we know is highly variable and unrel iable, we should be exa mining quality of motion . This resistance to motion, or lack thereof. is a n examin ation of the size a nd shape of the neutra l zone of motion ((rom zero to R1 or first resist­ ance ) , wh ich every j O int has. This is a dy namic feature of a j oint's intern al and external environment and is u nder ar ticu lar, myo fascial and neural infl uence. Researching qu ality o f motion . and n o t quantity. may provide us with better re liability between testers. When you watch a n experie nced clinician work and ask them what they are feeling, t hey often say, 'Th i s joint doesn ' t feel right. i t ' s gu mmy, o r i t gives way too e a s i ly ' . The i n experienced clinician will try to inter­ pret what they feel i nto a quantity of moti o n , 'f think this j o i n t is stiff or hyperm obile ' . They h ave yet to develop a n inventory of 'common feel ings ' . I s u ppose this is what you ca l l pattern recognition of sensory input. This, for me, is the development o f skilled manual technique. So to a nswer the second part of you r question, I weigh the significance of my m a n u a l examin ation t1 n d i ngs (of resistance not quantity of motion) h ig h ly when reaching a biomechanical d i agnosis. I do not reach a diagnosis based o n the fi nd i n gs of one test but rather on the res u l ts of the entire exami nation process. I look for resistance to motion or giving way

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to implied fo rces and put less emphasis on the a m o u n t of moveme n t I a m fee l i ng.



the res ults o f the en tire exami nation

rather t. h a n any sin gle test. i L l u strates


key tenet of

rea so n i n g . t h a t is look i n g for consist ency /support

• C li nical

for hypo t h eses across

reasoning commentary

As d iscu ssed in Chapter 1 . physiotherapy knowl­



propos itional acq u ired

b i o m ed i ca l

research-va lida ted

knowledge/const r u cts .



n u m ber of II n d i ngs. Even

when some II n d i n gs are weighed more heavily than

empi r i c a l ly

knowledge/cl i n ical

others. this style of reason i n g m i n i mizes the com­ mon



overt'ocussing on yo u r favo urite

hypothesis and not excl u d i n g competi n g hypo t h e­ ses . S i m i larly. given that o u r knowledge of pa i n a nd

i n ferences a nd personal know ledge. It is i m p or t a n t

physical impairment is still fa r from complete.

to rel ate. where possible. o u r ex a m i n ation and

acknow led ged b y t he cl i n ician i n her prev ious com­


t reatmen t i n terventions to the available biomedical

ments regard i n g the lack of t-isSlle spec i fic ity w i t h

knowledge, s u c h as the anatomical a n d b iome­

physio t h e ra py procedures, it i s cri t ical t o monitor

c h emical rati onale o u t l i ned here by the c l i n i c i a n .

the effect of all i n terventions t h rough re- assessmen t

t h e c l i n i c i a n discu sses , some o f our

of loca l tissue. flUlction a l and psyc hosoci a l/q ual ity

j u d gmen t s . such as motion of a j o i n t , cannot be

of l i fe effect s . This aspect of clinical rea so n i n g t he­

accu rately q u a n ti fied in

c l i n i c a l sett i n g . I n stead .

ory in practice i s evide n t in t he c l i n ic i a n ' s comments

t hos e c l i n i cians that carefully attend to sensory cues

regard ing re-assessme n t of horizo n t a l t ra ns l a t i o n

H o wever,



such as q u a l i ty of moveme n t and reflect ively relate


t hose p a t te r n s of sensory input to other features in

regard ing pa i n mec h a n isms, sources and ma n age

the p a t i e nt s presentation are able to learn from

men t strategy are fu rther tested . This crit ical level of


treatme n t .



hypot h es i s ­

their clIn ic a l experiences. The c l i ncian's comments

reflective reaso n i n g en ables therapists to c h a l lenge

regardin g the lim itations of movemen t tes t i n g .

their theories or presuppositions conti n u a lly and

a nd s u bseq u ent a pproach of b a s i n g her p hysic a l

adj ust their reaso ning appropriately.

fin ger. T6 is fixed by compressing the two seve n t h ribs towards the m i d - l i n e . Care m u s t be t a ke n to avoid fix­ a tion o f the sixth ribs , which m u s t be free to gl ide rel­

• F irst treatment

ative to the tra nsverse processes o r T6. The o ther

In s i m p l e l a n g uage that Julie c o u l d unders t a n d , the

h a n d / arm l ies across the patient ' s crossed arms to

firs t treatme n t i nvolved exp l a i n i n g what had hap­

con trol the thorax . Segmental loc a l i zation is ach ie ved

pened to her t h o rax . The symptoms were co-related

by flex i n g a n d extend ing the j o i n t u n t i l a neutra l posi­


tion of the zygapophyseal j o i n ts i s ach ieve d . T h i s


p a th o b iomechanics

a nd




patient/thera pist rapport a n d confidence was d e vel­

localization i s m a i n ta i ned a s the p a t i e n t is rol led

oped . A fter 1 8 m o n t h s , the motor pattern that s u s­

s u pi n e o n ly unti l contact is made be tween the table

tai ned the pathomec h a n ics was we l l established a n d

a n d the dorsal h a n d .

trea tment m a y wel l have provoked h e r symptoms i n i ­

From this posit i o n . T 5 and the l e ft and r i g h t six t h

t i a lly. T h e r e must be a good under s t a nding be tween

r i b s are tra n s lated laterally t o t h e rig h t t h rough the

patient and therapist if p a i n provocation occurs and

thorax to the motion b a r rier. S trong lo n g i t u d i n a l dis­

trust i s to be ma i n ta i ned.

traction is app l ied thro u g h the thorax prior to the

A G r a d e 5 technique ( man i p u l a tive thrust) was

appUc ation o f a h ig h -ve locity, low-amp l i tu d e thrust.

u sed to reduce the ar ti c u l a r compre s s i o n . The specific

T h e thrust is i n

tec h n i q u e when the s i xth thoracic ring i s held in rig h t

p l a n e (Fig. 1 0 . 4 ) . The go al of the tec hnique is to

rotation ( le ft l a teral tra n s l a tion) is desc ribed bel ow. The p atie n t is in left s ide ly i n g , the head s u ppor ted


l a tera l di rection i n the transverse

tra nsl ate 1' 5 laterally and the left and rig h t six t h ribs r e l ative to T 6 .

o n a p illow and the a rms crossed to the opposite

A rter t h e sixth segmenta l r i n g was d ecompressed .

shou lders. With the left ha n d , the right seventh rib is

the fu n c t i o n a l moveme nt, positio n a l . mobi l i ty and

p a l p a ted posteriorly w i th the thumb and the left sev­

stability tests were repeate d . No kink i n the spin a l

e n th rib is pa lpated posteriorly with the i n d ex or l o n g

cu rve was noted o n fu nctional move ment testing. The

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Fig 1 0 . 5

I s o l a t i o n of the segmental s p i n a l s ta b i l izers can

be fac i l i tated u s i n g n e u ro m u s c u l a r s t i m u l a t i o n .

Fig. 1 0 . 4

G rade V m a n i p u lation tec h n i q u e used to

( R e p ro d u ced by k i n d perm i s s i o n of Delta O rthopaed i c

red uce a fixated l eft lateral s h ift of TS a n d the sixth ribs

Phys i o t h e ra py C l i n i c , fro m Lee 1 994b.)

relative to T6. Strong a x i a l d i s t racti o n m u s t be m a i nta i ne d t h roughout the tech n i q u e . ( R e p rod uced by k i n d perm ission o f D e l ta O rthopaed i c Phys iothe rapy C l i n i c ,

low bac k i nj ury, and t h a t recovery i s n o t spon ta neous

from Lee 1 994b.)

without spec ific exercise i nstruction. Cl i n i c a lly. the same appears to be tru e i n th e thorax . The p rin c i p l es

positi on a l tes ts revealed symmetry between T 5 and

T 6 as wel l as the l e ft and right s i x t h ribs i n n e x i o n


neu tra l and exte nsion of the m id-thoracic spine. The

pass ive p hy s i o log i c a l and p as si v e acc e s s ory m o b i l i ty tests

reve a led


r e s i s t a n ce


m o t io n


t he

zygapophysea l j o i nts between T 5 -T6 a n d the costo­ tra n s verse j o i n t s of the le ft a n d right sixth ri b s . A n u n d e r ly i n g i n s t a b i l i ty o f left l a tera l tra nslation ( h o ri z o n t a l ) a n d rig h t rota tion was d et e c ted A sense .

of g i v i n g way was fe l t d u ri n g l eft l a te r a l tra ns l ation as oppos ed to


larger a m p l i t u d e of motio n . In add i t i o n .

a tro p hy of the segmenta l stab i l iz i n g m u sc les ( rota­

to res and deep m u l t i fidus) was noted .

The fu l l s l u mp position remained provocative, al tho u g h the pos i ti o n had to be held l o n g e r for the symptoms to be a g gravate d .

t a pe d to rem i n d Ju lie to avo i d rota­ tion in ei t h e r di rection (X t a p e across the T 5- T6 reg i o n ) . S h e was reminded that she ma y expe rience some i n crease i n b o t h her loca l a n d referred pain b u t that this wo u l d settle over the next 2 - 3 d ays a n d a The thorax was

sense o f i m proved mob i l i ty shou l d follow.

used in the th o r ax are identica l to those advoc a ted by

the research team [rom t h e University of Q ue e n s l a n d in Brisbane ( R i c h ard s o n et al . . 1 9 9 9 ) . Essentially, t he patient i s ta u g h t spec i fica l l y to recr u i t the s e g me ntal

mu sc le s i s om e trica l l y and t h e n 10. 5).

concentric ally while prone over a g y m b a l l ( F i g .

El e ctri c a l stimu l a t i o n c a n b e a usefu l a d j u nc t a t

th i s time. I n side lyi n g , spec i fi c se g m e n t al rotation c a n b e resisted by the thera pist both concentr i c a l ly a n d eccentrica lly to fa c i l i t a te t h e retu r n o f m u l t i fi d u s

fu nc ti o n . The programme is progressed b y i n creasing the l o ad the tho rax m u s t c o ntr o l. I n i t ia l ly, sc a p u l a r motion is i n troduced,

in particu l a r lower trapezi us

wor k . T he p atient m u s t con trol the neutral position

of the mi d t h o r ax t h r ou g h o u t th e s cap u l ar d epre s ­ -

sion . The goal is to te a c h the p a ti e n t to isolate scapu­ lar motion from spi n a l motion so that the s cap u l a d oe s n o t prod u c e spi n a l m o t i o n d u r i n g activities

involving the arm. Once c o n trol i s g a i ned over the

scapu l a , exerc ises i n vo lv i n g the en tire u pper ex trem­ i ty may be ad ded ( F i g . 1 0 . 6 ) . By i ncre a s ing the lever arm and th en the load , the mid-thorax is fur ther c h alle n ged


Gymnastic b all , pro p ri o ce p t i ve . b a lance

a nd res is tive work can be i n te g r ated i n t o the p ro


gramme as needed . The velocity of the exerc ises c a n

S u bseq u ent treatments

be i n cre ase d a cc o rd in g t o the patien t s work a n d recre­ '

The fir st g ro u p of muscles that must be addressed in

a t io n

d e man d s . I n i ti al ly the load should be a pp l ied .

stabil ization t he r apy of t h e thoracic spine are the trans­

b i laterally and then progressed to uni lateral work. At

ver sos p ina l

( m u l tifi d u s ) and erector spinae groups. Hides et a l . ( 1 9 9 4 , 1 9 9 6 ) h ave fo u n d that the d e e p

t h e c o m p l e t i on o f the programme. the patient should

llbres of mu l t i fi du s atrophy q u ickly fo l lo w in g an acute

sc ap u l a r motion

be able to isol a te specific spi n a l ex t e n s i o n wi t h o u t

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a nd control b o t h b i lateral a n d


very fe arfu l o f a ny ro tation fo r the next 3 d ays. She felt


sense of we ak n e ss i n her c hest accompanied

by a deep a c he when u nsupported i n s i t ti ng . S he was able to l e a r n specifi c a l ly to rec r u i t the deep seg­ mental stabil izers at T5-T6 very q u i ckly and pro­ gressed to scapul a r work w i t h i n 1 week. If she

the multifidus could be felt to ' s h u t down' or turn ofr. and

i n creased the lever arm or the load too qUickly,

she had d i fficulty sens i n g when this was happen i ng. This i s


d i ffi c u l t area of the spine for patients to pal­

pate themselve s ; however i t is critical not to overlo a d the s p i n e beyond i t ' s ab i li ty t o Fig. 1 0 .6

The exercise p rogra m m e p rogresses fro m

cen tral s p i n a l sta b i l ization to i n c reased l o a d i n g with s c a p u l a r con trol and fi n a l l y u pper extre m i ty contro l .

ach ieve motor contro l .

Ju lie was keen to r e t u r n t o h e r sporting activities , all o f which req u ir ed u pper ex tremity pushing a n d pUl l ing. Our most

d i ffic u lt task was pacing the exerc ise pro­

gra mme wi th o u t provoking fr ustratio n . T hrough o u t this prog ramme, the segmenta l ring remained ' u nsta­

u n i lateral arm m o t i o n thro u g h o u t mid-ra n ge . They

ble' to static o r passive testing in r i g h t rotation and

are advised to avoid a ny act i v ity that places the m i d ­

left lateral tra n s l a tion . Over a 3 - month period , she

thorax at the l i mit of rotati o n in the direc tion of the i r

was able to learn to control her sp i n a l position and

instab i l i ty.

grad u a l ly i ncrease the loading through her upper

This was t h e programme of instr u ction given to

ex trem i t ies. U n i l a teral loading thro ugh one a rm ( l eft

m a n ip u l atio n . she repor ted

or righ t) , which i nvolve d thoracic rotatio n , rema ined

increased local mid-thoracic pai n , a decrease in the

provocative for her. She was able to return to a high

J u l i e . S u bseq u e n t to the

lateral costa l pa i n and no aggravation of her visceral

level of skii n g a nd as lo n g as she u sed both arms b i l at­

sympto m s . She fe l t that s h e cou l d take a much deeper

era lly was able to manage the sail on her boat.

breath immed i a tely a fter the m a n i p u latio n . She used

U n i l a teral p u s h i ng or p u l l i n g ac tivities with her right

c a u t i o n w i th a l l l o a d ing throu g h her thorax and was

arm r em a i n s provocative.

REASO N I N G D I S C U S S I O N A N D C LI N I CA L REASO N I N G C O M M E N TA RY At your fi rst treatm e n t ses s i o n , you seemed to

(pain) or prinCi ples of stabilization therapy. When

p l a c e a l o t of em phasis on ex p l a i n i ng the p ro b ­

exerc ises are done with awareness of what is. or

l e m to th e patient. Can you co m m e n t on t h e

should . be happening, lear n i n g is facilitated . The non­

ro le you see of teaching a n d exp la nati o n i n yo u r

thoughtfu l appro ach to exercise

pati e n t m a nage m e n t ?

in this manner. t h ree times per day regardless of how

( mo ve 2 kg 10 t i mes

yo u fee l or how you achieve the task) can be da nger ­ ous or, at min i m u m . may merely reinforce the poor

• C l i n ician's answer I


h ave found that the more the patient und erstands

regard i n g t heir condition , the more foc ussed and com­

prog ramme



m a i ntaining



fu nctio n . So. right [rom the begi n n i n g . education is a cri tical par t of the rehab i l i tation p rocess.

m i tted they become i n the recovery process. Le arn ing requires concentration and foc us; i n other words , a

Havi ng d etected the u n d e r l y i n g i n s tab i l i ty,

patient must be aware of t he processes t h at are occur­

p l ease elaborate o n yo u r rati o n a l e fo r

ring i n their bod ies i n order to effect a change. This is

yo u r fu rther manage m e n t with t h i s

true whether we a re explai n i ng symptom behaviour

pati e n t.

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' awareness' compon e n t o f the exercise to re-estab l i s h

• Clini cian's answer Physiotherapy cannot restore articular integ rity ( form closure ) : there fore, the emphasis of t r ea tment must be

appropri a te neura l con necti ons


on the r estoration of motor control ( force closure)

• Cl i n ical

( V leemin g et a1 . . 1 9 9 0 a , b ) . The go al i s to con trol the

The importance the c linician places on the pa t i en t s

excessive neu tra l zone of lateral tran s lation and rota­ t ion d uri ng fu nctio n a l activ ities and to avoid the end­

ranges of rotatio n , thus limiting the chances of fur ther ar ticu lar compression . This is accomplis hed thro ugh specilk exerci ses a u g m e n ted Vlrith muscle stimul ation . See ing how the onset of this lady's symptoms was trauma, do you feel th e re were any contributing factors (physical, environmental/ ergonomic,

reaso n i n g c o m m e ntary '

understanding and learning is consistent with the significance of pat ien t cognition i n t he mature orga nis m model h ighlighted in Chapter 1 . Patients' u nd er sta nd in gs and feelings are now recognized as signific a n t aspects of their pain experience, con­ tributing to their u n ique presentation and potentia l for recovery. Evaluat i n g patients' u nderstandings as potential con tributi n g factors to their health and also as a necessary prerequisite to guide the expla­

psychosocial, etc.) that were partly res ponsible

n ation and ed ucation that wiU be required t o effect a

for p ro l on ging h e r sym pto m s and disab i lity ?

ch a n ge in their health a ttitudes and behaviours is an i m po rt a nt focus that must be incorporated in therapists' reasoning. That i s , improving patients'

• Clinician's answer This



straigh t forwa rd

health requ ires much more than physical d i a g nos­




tic reasoning: t h er ap ists must also be able to recog­

trauma most l ikely resulted in a j o i n t fixation that d id

nize the other psychosocial and environ mental

not resolve spon taneou sly. as some wi l l . resu lti n g i n

determinants of hea lth and use their skills as teach­

conti n ued sy mptoms a n d disabil i ty. While y o u would

ers to effe ct the necessary ch an ges . This di m e nsion

ex pect a muscu l oskeletal soft tissue i nj u ry to complete

of our reasoning is promoted when clinicians adopt

its healing muc h sooner t han the 1 8 months this

a broader model of health a n d disability, as encour­

lady's sym ptoms h ave persisted , i t has been my experi­

aged in the mature organism model, and practise

ence that such prob lems c a n frequently be ma in t ai n e d

the sh ared decision-making strategy de p ic ted in the

this long wh en a j o i n t fix ation is present.

collaborative reasoning mode l

When recovery does not occur when expected ,


The c linician's answer to rea s o n ing question 3

patients begin to fe ar t h a t they will never get com­

n icely highlights how impairment in the mind-body

ple tely be tter This fea r c a n lead to psychological

connection can manifest not o n ly as an un h e l pful

states that can a mpl i fy the symptom ex perience.

perception , contributing to or d riving a patient s

Ch ron ic pa i n from a body p a rt can res u l t in d i ssoc i­

pain , but also as faulty motor programmes , as

ation i n the bo d y- m i nd connection. Even a fte r the biomec h a n ics are restored , the body-m i nd con nec­

reflected in a patient's learned postural an d move­ ment patterns. Again teaching as a focus of reaso n

tion must be addressed ; this is not necess ari ly auto­

ing becomes important. Education to alter a patient's




matic. Exercises for ra nge of motion , or wh a t has

awareness is central to this clinician 's approach in

been called ' m o tor prog rammi n g ' or seq u encing of

promoting improved motor programmes and is con­

movement patterns ' , sho u ld be ta ugh t emphasizing the

sistent with modern theories of learning.




segmen t al r i ng

is v u l nerable s h o u ld

s h e susta i n

a n other ri ght rotational i nj ury. f n the mea ntime, she J u l ie sust a i ned a n inj ury that caused a s tatic instabil­

has received the education she needs to m a i n t a i n her

ity of her mid-thorax. The pass ive structures t h a t

dy n a m ic stabil i ty a n d i f she conti nues to take care o f

restr ai n ri g ht rotation and left la tera l tra nslation h a d

this segme n t and c o n trol the d e g ree o f

become s tretc hed an d s h e req u i red a n optim al force

thro u g h th is part o f her spine, she s h o u l d be able to

closure mec h a nism to re m a i n functio n a l . The T 5 -T6

c on trol her sy mp toms

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â&#x20AC;˘ References H i d es. JA .

Sa i d e . M .. Ju l l . D. H. ( 1 9 9 4 ) . Evidence o f l u m bar m u l t i fidus m u sc l e s wa s t i n g i ps i l a te r a l to symptoms i n p a t i ents w i t h Stokes. M . J . .

C A . Coo pe r.

Cervical a n d Thor a c i c Spine. 2 n d edn

( R . Grant. ed . )

pp. 4 7-0 4 . New

C b u rc h i l l Livi n gsto n e . Lee.


(l 9 9 4 b ) . M a n u a l Therapy

a c u te / s u b a c u te low b a c k p a i n . S p i n e .

the T horax-a Biomec h a n ical

1 9 . 1 0 5- 1 7 7 .

Approa c h . De l t a

I-T ides. JA . R i c hard s o n . C . A . .

lu l l. C . A .

( 1 9 9 6 ) . M u ltifidus r e co ve ry is n o t fo l l o w i n g reso l u t i o n o f

York: for

BC: Del ta Orthopaedic

P hysio thera py C l i n ic.

Lee. D.G . a nd

V leem i n g . A . ( 1 9 9 8 ) .

a u tomatic

lm pa ire d load transfer t h ro u g h the

a c u te fi rst e p i s o d e low b a c k pa i n .

pel v i c g i rd l e : a new model of a l tered

2 1 . 2 7 6 3-2 7 6 9 . D.G. ( 1 9 9 3 ) . Biomec h anics o f the thorax : a c l i n ic a l model of in v i vo fu ncti o n . } o u rna l of Ma n u a l a n d



Ma n i p u l a tive Th era py. 1 . 1 3 -2 1 .

D. C. ( 1 9 9 4 ,, ) . Bi o m e c h a n i c s o f the t h o ra x . I n P hys i c a l T h e r a py o f the


n e u t r a l zone fu n c t i o n .


Procee d i n g s

from the T h i rd I n te rd i s c i pl i n a ry Wo rld Congress on

Low Rack and 1 9 9 8 . Vien n a ,

Pel v i c Pa i n . N ovember

Austria . R ic h a rd son .

C . . J u l l . C . . Hod ges . I' anJ

Hides . J . ( 1 9 9 '1 ) . Therape u t i c exercise

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for spi n a l segme nta l s t a b i l iza t i on in low b a c k pa i n . Ed i n b u rg h : Churc h i l l Li v i n gstone. V l eemi n g . 1\ . . S toeckart. R .. Vo l kers. A . C . W. and Sn ijders. C.}. ( 1 9 9 0a) . Rela t i o n between form a n cl fu n c t i o n in the sacro i l ia c j oi n t . ] : C l i n ic a l a n a tom i c a l a s pects. S p i n e . ] 5 . 1 3 0-- 1 3 2 . Vleem i ng. A . . Vol kers . A . C . W. . S n i j ders .

C.}. a n d S(oeckiJrt. R.

( 1 9 9 0 b ) . Re l a t i o n bet ween form

a nd fu n c t i o n i n t h e sacro i l ia c j o i n t . 2 : R iomcc h a n i c a l aspects. S p i n e . 1 5 . 1 3 3- 1 3 0 .

Bilateral shoulder pain in a 16-year-old long-distance •

sWimmer Mary Magarey


Sally is a 16-year-old school girl u n dertaking her final year of schooling at an exclusive coed ucational pri­ vate school. She is from a family of t h ree children and one adopted daughter. Her father is a doctor and her mother a teacher at the same school attended by Sal ly


She is a high achiever academica lly and appears a we ll adj usted if q u iet girl. She is a lso a high level dis­ -




tance swimmer. with freesty le and butterOy her main events. At 14 yea rs of age. she was a national level swimmer but had not been able to achieve this stand­ ard for the last 2 years because of difficulties with shoulder pain. She came to me on the recommenda­ tion from the physiotherapist mother of one of her II

swimming contemporaries.

History Sally's presenting problem was one of bilateral shoul­ der pain. as indicated on the body chart (Fig. 11.1). worse on the left. t hough the side dominance varied [rom time to time for no apparent reason. She had the

pain in both shoulders whenever she swam and developed an ache in the same areas after swimming. This ach e lasted for 2 to 3 hours after swimming and her shoulders generally felt 'sore' at all times when she was in peak swim training. Her worst pain was with butterOy, on both recovery and mid p ull -through aspects of the stroke. She also had similar pain with freestyle


particularly at the catch and mid puIl­

Fig. 11.1

Body chart demonstrating Sally's presenting

pain picture. The pain was intermittent with swimming with the ache in the same area after swimming. There was no

through, t houg h the level of pain was lower. The pain

pain in the cervical or thoracic areas, arms or hands. There

was present as soon as she started swimming. was not

were no pins and needles in the hands or feet.

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sufficient t o prevent her from swimming, but inhibited

training. Her left shoulder pain, in

full training and progressively worsened through


the right, began some time later with no apparent

training session. She had no specific pain or difficul­

specific precipitating incident. Since then, both had

ties with other activities but did not play other sports

followed the pattern described above.

that would put the same load or challenge on her

same area as

with Sally's a 'shoulder s\'limmer'.

We discussed swimming technique,

shoulders. At the time I first saw her it was the end of

mother indicating that Sally was

the summer swimming season, during which she had

getting little erfect in her stroke from her kick. I explained

been swimming for eight 2 hour sessions every week

how improving body roll and kick power could decrease

with a predominance of training in freestyle. She had

the load on her shoulders cmd, therefore, might reduce

just started



month lay-ofr from training before

beginning a slightly lighter load through the winter. Sleeping was no problem, even lying on her

and she had no morning stiffness. She took no anti-inflammatory or pain medication. Sally was in good general health and appeared to have no other


identinable problems. Investigations included plain

the pain associated with her swimming, even though the kick is not as significant swimming as

it is of


component of distance

sprints (Maglischo.


We dis­

cussed the possibility of working on these aspects of her stroke with her coach, in adclition to whatever specitlc problems were identified in her shoulders. Her mother,


did most of the talking



radiographs, diagnostic ultrasound and computed

visits, told a saga of attendance at multiple health


professionals in an attempt to lind a diagnosis for and



none of


demonstrated any abnormality.


resolution of Sally's shoulder pain.

years earlier, when Sally was training for

est to me


Of particular inter­

the information that she had attended

the national swimming championships, she lifted a

live clifferent physiotherapists, none of whom, in Sally's

heavy suitcase and felt something 'pull' in her right

or her mother's opinion, appeared to have given satis­

shoulder with immediate pain in the anterior sub­

factory treatment. I found this information quite

acromial/superior capsular area. This pain was not

dauntingl The

severe but did not go

Table 11.1


disrupting her swimming


agement is given in Table

of investigations and man­


Previous professional consultations before presentation

PhYSiotherapist 1 Orthopaedic surgeon

Treatment provided was ultrasound and interferential. with no benefit Ordered plain radiograph. ultrasonography and computed tomographic arthrography, all of which were negative. He injected what appeared to have been her subacromial space. with no relief of symptoms. even temporarily. He was not prepared to offer arthroscopic investigation because of her age and lack of findings on the diagnostic imaging

Physiotherapist 2

This physiotherapist worked in a sports specific physiotherapy clinic and had many years of experience with national level sports teams. Treatment prOVided included further electrotherapy and some basic rotator cuff exercises, again with no benefit

Sports physician

He indicated that she had sloppy shoulders and that she needed an exercise programme directed at her shoulders. He referred her to physiotherapist 3

Physiotherapist 3

T his physiotherapist had considerable experience in treatment of postoperative shoulders and worked in a sports-specific clinic. She was also experienced with national level sports teams. Treatment provided was shoulder and scapular stabilizing exercises (as far as could be ascertained from the description). Sally worked at the exercises but became disillusioned when the physiotherapist would not allow her to get back in the water to swim. It appeared that Sally probably did not give this programme a fair trial before looking elsewhere for assistance. Her mother's comment was 'It is hard to fit all that exercising in and swim and do homework'.

Physiotherapist 4

T his physiotherapist was a national level swim coach who had practised more as a swim coach than a physiotherapist. but who had specialist knowledge of swimming requirements and a depth of understanding of the psychological issues related to working with swimmers.


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Table 11.1

Previ ous professional consultations before presentat i on I n parti cular he understood how important it is for swimmers to be able to stay in the ,

water during any rehabilitation. Treatment provi d ed included further exercises and stretchi ng with an emphasis on medial rotation of the shoulder. My und er stan d ing was that neither Sally nor her mother got on with this physi otherapist and the decision to cease treatment was based more on this than any failure of the treatment regimen. Chir opra ctor

No specific details of the chiropra ctic treatment were elicited, except that the chiroprac tor told Sally to 'swim through it'.

Phy s iotherapist 5

T his physiotherapist was also a sports orie nted physiotherapist with extensive national and -

inte rnatio nal team experience. T he comment from Sally's mother was that this was 'going down the same old path' and they did not persi st with her. General practitioner

This general practition er had an interest in na tural medicine and gave Sal ly eight inje ctio ns of glucose over a period of some months. This treatment appeared to help Sa ll y more than any other, although Sa ll y s mother was unable to explain to me the theo retical basis of pain '

relief related to glucose injections. T he benefit of these injections lasted approximately 12 months but she had not returned for further therapy when the shoulder pain returned ,

� IJ D



Based on the initial information regarding the

The bilaterality of her pain. while common with a sport that involves bilateral load on the shoulders,

patient's personal profile, her presenting

could also be

as well as the history of onset for the symptoms

impairment, while the anxiety created in an elite

in both shoulders, what were your hypotheses

athlete by impairment that prevents participation in


reJlection of

a neural processing

symptoms, general health and investigations

at that stage regarding dominant pain

the chosen sport could contribute to the presence of

mechanisms, possible sources and contributing

an affective component to her problem. The apparent dominance of her mother in the

factors for the symptoms and activity/ participation restrictions she was experiencing

interview situation also raised questions about Sally's

in her two shoulders?

ability to mal<e decisions for herself or speak her own

• Clinician's answe r

responsibility for her symptoms and their manage­

mind. with the inherent potential of

not taking

ment. I also wondered whether her mother's level of

Dominant pain mechanisms

involvement in telling the story indicated that she was

The dominant pain mechanism I considered with

the driving force behind Sally's continued pursuit of

this girl was an input nociceptive mechanism. My rea­

a swimming career. rather than Sally herself. This

soning for that related to the very mechanical nature

thought may seem a bit harsh, but this is a common

of her symptoms with the on/off features related to

scenario in individual sports such as swimming and

If this were the case. it would be likely to

her swimming and the localized site of symptoms.


However, there were elements of her presentation that

have a Significant inJluence on Sally's motivation

made me also consider other mechanisms. For exam­


ple. while the history of onset of the right shoulder







pain sounds mechanical and. therefore, supports a

Sally's family situation seemed financially secure.

nociceptive disorder. the onset of similar pain in the

settled and happy. but the older adopted sister was a

left shoulder without a provoking incident could indi­

high-level sprinter. so there was the possibility of

cate the presence of some central sensitization of her

Sally feeling that she needed to achieve to keep up

symptoms. There were also a

number of features that

could have supported this hypothesis.

with this older family member, again with potential inJluence on the outcome of any management.

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Sally was also in her last year at school. a high aca­

However, with an understanding of the load placed

demic achiever who indicated that she was keen to try

on both shoulders 'with swimming, particularly with

to study medicine on leaving school. This goal would

butterfly, I considered it more likely that her problem

obviously create significant pressure to achieve aca­

related to similar mechanisms in both shoulders

demically, possibly altering the perspective with which

rather than somatic referral from a spinal source.

swimming was seen from that of earlier years. These features raised the question about whether Sally was using her shoulder pain as an excuse to back away from swimming without seeming to be giving up or failing to achieve in the same way as the older sister. However, a typical feature of high-level junior swimmers is hypermobility of the glenohumeraljoints coupled with altered muscle balance and control around the shoulder girdle in particular (Pink et aI., 1993; Scovazzo et al.. 1991). The history of a traction injury to the right shoulder as the original provoking incident seemed to fit a nociceptive presentation, with the likelihood that the other shoulder became painful as a result of Sally adapting her swim technique to try to avoid pain in the right shoulder. With the likely underlying hypermobility in both shoulders and the high load generated by swimming, particularly butter­ fly in which symmetry of stroke is essential. such a scenario seemed reasonable. With the advent of pain, muscle function around the shoulder girdle, and in particular in the rotator cuff. is likely to have been affected, such that an imbalance already present from the involvement in swimming would be accentuated. Therefore, while the potential for central sensitization and an affective component to be features of the pre­ sentation was definitely there, my favoured hypothesis

C o n tributin g factors As indicated above , I considered it highly likely that Sally had a strong contributing component of poor dynamic control of her shoulders. The particular fea­ tures of her story that support this hypothesis are the history of the pain associated speCifically with a sport that involves large repetition of the same action undertaken almost daily, with little chance. therefore. for recovery, added to little involvement in alternative physical activity and coupled with the stress of final year schooling. Knowledge of the loads required of the joints and muscles in swimming also led to support of this hypothesis and recognition of what is. in fact, a very common clinical pattern in high-level swimmers. Therefore, the reasoning supporting my hypotheses was based in part on Sally's particular presentation but also on my underlying recognition of the particu­ lar clinical pattern.


What were your thoughts after obtaining the histor y of previous management? Specifically what hypothesis categories were most informed by this add itional in formation and in what way !

at this stage was one related to altered motor output, with her pain perpetuated by excessive load on struc­ tures not adequately stabilized to cope with it. Poor

• C l i n i c ian's answer

muscle control and dynamic support of her shoul­

I had a number of thoughts about the history of pre­

ders and shoulder girdles seemed most likely to be a

vious management. Initially, I was disappointed to

dominant feature of her presentation.

hear what appeared to be tale of mismanagement of an elite athlete, even by health practitioners attuned to the needs of such patients. It also reinforced for

Sources of pai n

me the importance of understanding a patient's sport

M y main hypothesis about the source of Sally's shoul­

and the particular needs of athletes within that sport.

der pain was the capsule of the glenohumeral jOint,

and relating management to those needs as much as

with the possibility of involvement of the superior

is reasonable. Even if it is not possible to relate man­

labral structures adjacent to the biceps anchor and of

agement to the specific requirements of a particular

the biceps tendon itselJ. I also considered the rotator

sport. at least demonstrating an understanding of the

cuff as a possible contributing source of her symp­

needs of the athlete and providing reasons for a par­

toms. The bilaterality of symptoms meant that I

ticular management goes a long way to addressing

had to consider the cervical and thoracic spine as a

the cognitive/affective components of

potential source , with somatic referral to the shoulders.

establishing this history in such detail. I was also

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problem. In


trying to flnd out whether the approach to treatment

ti ci pa ted would be effec t iv e had been tried in the past. because if it had the chance of success from my management was l ower. that I


Did you judge the mother's apparent dominance of the interview to be simply

trad itional approaches to s at is fy this family's needs, even tho u g h that was the b ackg rou nd from which t h ey c a m e . These considerations highlighted to me how imp o r tan t it was to provide a rational e xpla na t i on for my suggestions for management if I was to have any success in con vi nci n g them of its p o te n ti a l val ue.

typical of a parent or could this a n d their apparent understa nding and beliefs about what was required to rehabilitate Sally's

• Cl inical

shoulders be seen as potential contributing factors to her lack of success to date a n d something that would have t o b e addressed?

In discussing hyp othe ses at pre sentation regar din g


pain mechanisms. poss ible sources and

contributing factors lor the symptoms and ac tivity/

• C l i n i cian's an swer

participation restrictions. the clinician illustrates her

This question is somewhat diCl1cult to answer, a s the p ar ent who i s supportive and tuned into th e needs of an a do le sc ent athlete s howi n g considerable poten­ tiet! will t e n d to do an y t h i n g to help them to succeed . Such pe ople . as a t h l e te s themselves ofte n do. tend to want a quick answer to a problem and will 'shop around' in the h ope of IIndin g one. Therefore. S al ly 's mother could be viewed in this light a nd , at the time. t h is was my m ain interpretation of her motives. However. so-called 'pushy' parents are commonly seen associated with i n divi d ua l sports such as swimming and this image did come to mind somewhat. particu­ larly listening to her description of the list of attempts to lInd an answer to Sally s problems. My hypo theses, ou t li n ed in the answer to Q ues t i on 1 about S a lly's mother's influence on prognosis in p ar ticul ar, contin­ ue d t h r oug h this part of the inter v i e w. The comment about difficulty fi tti ng in the exercise w it h s t u dyi n g and s w imm ing did make me question their commit­ ment to success of a managemen t programme. I d i d find it in teresting that this fa m i ly had aban­ doned traditional pathways in th e i r attempts to solve Sally's pr o blems . with their use of a ch i ro practor. a l t ho u gh this sounded like it was short lived. and the apparent success of glucose injections despite their inabilit y to explain the hy pothesized mechanisms by which glucose injections would help painful shoul­ ders in an adolescent swimmer. Clearly, the injections had been ben eficial. but what surpr is ed me was that neither mother nor dau ghter had any idea of the pro­ posed mechanism of their effect. The fact that use of the chiroprac tor an d a somewhat alternative method of management of musculoskeletal disorders were sought late in the pie c e suggests a fa ilure of the more '

reaso n i n g co mme ntary

thinki n g on mu ltip le levels. Wh il e her thinking has occurred now in hinds ig h t in resp o n se to the specillc question asked. expert clinicians are also ab l e to think in this manner as they work through an exam­ in atio n The c 1inician s answers her e also reflect a hypothesis-oriented abil i ty to re cog n ize a broad range of diagnostic issues, i ncluding pain mech­ anisms. sources and physical c ont ri but ing factors. in addition to psychosocial fe atures in the patien t's presentation. incl udi ng her rela ti on ship with her mot her The hypo t heses considered are not closed at .



this early stage; rather they


clearly informed by

c onsi de ra b le experience with sho ulder prob le ms and prov ide an initial picture against which subsequen t information will be considered. Understanding a patient's tmderstanding the patient.




clinician's think­

ing goes well beyond analysi s of s hou l d e r impair­ ment. with ser iou s consideration also give n

to this

pa tien t s personal context. including the specific '

needs of h er sport and the relationship she has with her mother. While the likely n e ed for act i ve management has been hypothesized. the impor­ tance of teachin g (e. g. ex plan a t i o n ) in this patient's management is also emphasized. that is not Simply teaching to do (Le. instrumental le ar n ­ ing) but t e aching to promote altered understand­ ing and fe e l i n g s (Le. tr ansformat ive learn in g). This level of teaching must be ba sed on ass essme n t of the patie nt's (and in this case the m o ther s ) under­ s t an ding and feelings, in cl ud ing the basis of those thoug h t s and emotions (Le. pr e vious advice. past medical experiences. pe r s o n al goals and pres­ s ur es) Expert clinicians must be ex pert teachers. '


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For the physical examination, Sally u n dressed to her swimsuit. Observation demonstrated the broad shoulder. narrow hip posture typical of an elite swim­ mer, with very horizontal shoulder girdle, wid ely pl aced scapulae and sli ghtly m edia ll y rotated shoul­ ders. There was no apparent asymmetry i n her shoul ­ d er girdle posture or muscle development. Her upper quarter musc le d evel opm en t was n o t outstanding. Spinal posture a ci c

re ve al ed

a slight ly ex agg er ated th or ­

ky p hosis and lumbar lordosis. also typical of

swimmers, and the tone in her abdominal muscles. gluteal muscles and legs appea red go od .

Furthe r tests Isometric rolator Cliff test s.


was no pain but

the impreSSion of poor power, particularly in lat­ eral rotation. Specillc t ests for long head of biceps in different positions were negative. Active movements of the cervical and thoracic spine


This was generally mob i le to hyp er mobi l e with no pain loca lly or in the shou Iders. Neural provocation tests of the upper limbs.


ab n ormali ties were detected in the upper limb ten­ sion tests l. 2B or 3

( B utler, 2000). Test 2A


not carried out as I co nsi der ed that any ab n orm al­ ity in the median nerve component of the neural


Glenohumeral joint flexion and abduction.

glenohumeral j oi nts were


hype rmobile an d there

was excessive s capul ar rotation. There was no pain

any ab nor m alit y related to sc a pul a r depres­

sion and protraction would h ave been obvious with test 2B. Glenohumeral joint stability tests.

The mobility

rating scale used to evaluate shoulder translation

at end-range nor with overpressure. Glenohumeral joint medial rotation, measured in

There was normal

abduction and full flexion.

with test 1

structures would have been detected

Active shoulder moveme nts

tests is similar to that used for measurement of mobility with


La ch ma n



test for the anterior

range in b oth shoulders in both positions, with

cruciate ligament. (Normal mobility is rated as

some slight discomfort on overpressure to medial

zero. with three measures of increa sed laxity: +.

rotation in full ll ex i on . This position was tested as i t is





m oderat ely

translation ; + +.

translatio n;

and + + +.


movement emph asiz ed b y swimming coaches



in cr eased translation, to subluxation. This rati n g





during the catch phase of the freestyle or b utterlly st r oke . Glenohumeral joint lateral rotation measured in abduction and full flexion.

There was a sligh tly

scale is used by l ocal orthopaedic surgeons and phy siother a pi sts

but has not been validated.) Using

this rating scale, the anterior drawer was hyper­ mobile (+)

w ith

right greater than left. Posterior

increased range com pa red with what might be

dr awer was hy per m ob il e (+ +)

expected as normal, with a 'loose' end-feel. No

than right. The inferior and anteroinferior glid e


was slightly hypermobil e on both sides. No appre­

Hand behind bac/(.

In t h i s posture, there was nor­

mal mobility of both shoulders, com b i ned with excessive winging of the medial border of the scapulae. Stabilizat ion of the scapulae did restrict

w ith left greater

hension or pain with any s tabi li ty test. All tests had a s l i g h tly loose end-feel Passive physiological and accessory movements of the glenohumeral joint.

All movements were

glenohumeral jOint range; however, it could still be

hypermobile with a loose end-feel. Quadrant

considered within nor mal limits.

positi o n , on the low side of the quadrant, repro­

Horizontal flexion and extension.

Gen eral l y hyper


mobile, with no re p roduc tion of symptoms. With all





duced Sal ly s pain on b oth shoulders. Differ enti al '

testing in that position demonstrated increased pain



di st rac t ion



movement of the scapulae was evident, with poor

pain on subacromial compression and a slight

stabilization of the medial border so that arm

increase on glenohum e ral compression, indicat­

m ovem ent was accompanied by sc apula r medial border winging.

ing a p robab le c apsular source to her pai n with a possible slight con tri b uti on

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from something


Fig.1 1.2

Dynamic rotar y stabi lity test d e monstrated in

the catch position of the freesty l e stroke. the position in which Sal ly's symptoms were most evi d ent (Magarey and Jones.2003a).

Fig. 1 1.3

Rotator cuff dyna m i c relocation test

(Magarey and Jones. 2003b).






Maitland. 1991).

90 degrees of flexion. abduction or scaption. with

Passive movements of the scapulot/lOracic joint. All movemen ts were hypermob ile with a loose end­ feel. with a particularly mobile scapular abduction and lateral tilt ( winging ).

quite marked weakness in these positions.

Rotator cuff dynamic relocation (concavity compres­ sion) test. This test is shown in F igure 11.3 (Jones and Magarey. 2001; Magarey and Jones .

Passive movements of the acromioclavicular and

20m a . b) . With the arm in the plane of the scapula

All hypermobUe. particu­

and approximately 60 degrees of abduction. Sally's

sternoclavicular joints.

larly posteroanterior glide on both acromioclavic­

ability to generate a stabilizing co-contraction of

ular joints and posteroanterior glide on the left

the rotator cuff was very poor. With considerable

sternoclavicular Palpation.




facilitation. she was eventu ally able to achieve it. areas




a ltered tissue texture could be found. In particular.

but with poor-quality contraction.

Side-lying scapular proprioceptive neuromuscular

long head of biceps. supraspina tus insertion. the

facilitation (PNF) diagonals.

subacromial and subcoracoid spaces and the pos­

position of the scapula

terior joint lines were clear.

of the scapula in the four diagonals, even follow ing

Dynamic rotary stability test.

This test is shown in


Aw a reness of the

di fficul ty in movement

facilitation. was tested (Magarey and J ones . 2003a)

Figure 1 1. 2 Uones and Magarey. 2001: Mag arey cmd


Jones. 2003a.b). No shifting of the humeral head

four corner positi ons (up and forward s . down and

could be detected during testing in any position. but

back. up and back. down and forwards) against

there was poor quality of contr a ction of both medial

any resistance was poor. particularly down and

and lateral rotalors. par ticularly in positions above

back. which is predominantly lower trapezius


Copyrighted Material

Sally's abi lity to maintain any of the


contraction. In the up and forwards movement. she had a tendency to go into forward movement of the shoulder girdle rather than upwards. with this forwards movement representing a protraction and anterior tilt of the scapula with


lack of the

elevation component. While this movement was not ideal, it was not as signilkant as the lack of down and back movement. I chose to omit examination of

accessor y move­

ments of the cervical or thoracic spine on Day 1 because I wanted time to assess dynamic stabilization of the glenohumeral joint and Lhe scapul a on the Fig.11.4

Scapular proprioceptive neuromuscular

chest wall.

facilitation pattern of'down and back'-the direction in which Sally's awareness and control was found to be particularly poor.

� I J -



Please h ighlight h ow the i n formation from the

Sources of symptoms and contributing

p hysi cal examinati on d i d or di d not support


your previous hypoth eses rega rdi ng dom i n a n t pa i n mech a n i sms, source of the sym p tom s and contri b u ting factors?

The only physical test that reproduced Sally's pain was the





1991). The quadrant is not a test that identil1es spe­ cific structures at fault. but it does appear to be a sen­

• Clinician's answer

sitive clinical test for detecting abnormalities around the shoulder complex. The details of how to under­

Pain mechanisms

take this testing can be found in Maitland (1991).

My physical findings supported my primary hypoth­

Further discrimination of source can be made with

esis of an input nociceptive problem coupled with an

the differential testing described above. Differential

impaired outpu� motor mechanism. The support for

testing involves altering the stress on structures

this hypot hesis was partly the lack of findings that

within the subacromial space. the glenohumeral jOint

would support any other mechanisms. Sally demon­

capsular structures. intra-articular sLructures and

strated none of the physical features that tend to be

the acromioclavicular joint. The responses to such

identified with centralization: for example, hyperalge­

testing with Sally indicated positive responses for a

sia, inconsistencies in response to physical testing, and

glenohumeral capsular source to her symptoms, with

spontaneous pain. Also, she showed no features that

her pain exacerbated by increasing the stretch on the

readily supported the possible affective component

capsule with the shoulder in the provocative quad­

that had been hypothesized during the subjective

rant position (subacromial distraction) and decreased

examination, with Sally cooperating fully and openly

when the stretch was reduced (subacromial compres­

with all aspects of the physical examination. Her

sion). Extrapolation from anatomical and biome­

responses to physical tests were consistent and she did

chanical analysis related to restraints to movement

not display an obvious fear-avoidance or inappropri­

would indicate the rotator interval/coracohumeral

ateness in her responses. The mechanical nature of

ligament region as the strucLures most likely to be

any symptoms found and the poor muscle control of

responsible for this pain. There was also weak support

her glenohumeral joint and scapulothoracic articula­

from differential testing for an intra-articular compon­

tion also supported my primar y hypothesis.

ent to the pain (there was some slight increase in her

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1 1 B I LAT E RA L S H O U L D E R PA I N I N A 1 6- YEAR- O L D L O N G - D I STA N C E SWI M M E R

symptoms with t he a d d i ti o n o f glen ohu mera l com­ press i o n to the qu a d r an t position ) , in th is case, prob­ ably superior l a bral in o ri g i n , T h erefo re


• C l i n i cal

reaso n i n g c o m m entary

The hypoth e s i s te s ti n g for p hy s ica l impa i rments

m y hypothesis related t o t h e gleno



a ss o c i ated

sources that was ini ti a ted in the

h u meral j Oint as the primary source of symptoms, with

subjective ex a m i n a tion is continued through the

the superior c a psular and lab ral structures assoc i a ted

physical ex a mi na ti o n

with the b iceps anc hor as the most l ikely so urce, was

does not sim ply follow a predetermined series of


Importantly. the cl i n ic i a n

supported by the p hysical findings, The hy permobility

sh o uld er

of the whole shou lder gird le also su ppo r te d my hypo th ­

di rec tly related to earl ier hypotheses generated and

assessments; rather tests chosen are

esis, The fact that the fi ndin gs rela ted to pa in provoca­

the patient's particular presentation . The depth of

tion were m i n ima l a lso su ppo rted my hypothesis that

the cl i nici a n s physical examination is a ppa re n t in

th ere was little or n o intri nsic pa tho l ogy with t h e p a i n

her assessme n t of muscle fu n c tion , which incorpo­

primarily r e la ted to irritation o f these str uctures as a

rated important aspects such as patient a wa re ne s s


resu l t of poor muscle c on trol of the hy permob i l i ty, Lack o f fi n d i ngs rel a ted to the neural provocation


and timing of activa ti o n assessed thro u g h a c o m .

b i n ation of functionally relevant proc ed ures

tests an d normal a ctive mo b il i ty of the cervical and

a pp a rent

A l so



in the clin icia n s reason i n g is he r '

thoracic spi ne negated these structures as sources,

open mindedness with reg a rd to the hypotheses

altho u g h I recognized that this could not be com­

con sid ered , A common error in cl i ni c a l reason i n g

p letely e l i m i n a ted from my th inking as the examina­


tion of the spine was not complete.

re cog n i ti o n i s the d i ffic ul ty c l i n icians have in t r ul y

The hy po th esi s rel a ted to c o n tri b u ti n g fa ctors of

b i as


a n d t h e g r e a t e st hindra nce t o pattern

hypo th es e s e nt er t a i n s a n um­

conSideri n g a n d d i s pr o v in g co m petin g

poor muscle c o n trol was s tron gly s u ppor ted by the

( see Ch . 2 6 ) . Here the clinician

p hys i c a l fi nd i n gs o f lack of dy n a m ic c o n trol o f the

ber o f d i ffere n t hypotheses , noting th ose that are

glen o h u meral j o i n t and sc ap u l o thor a cic

su pp ort e d and those that are n o t s u p po r t ed by the

duri n g d y n a m i c a n d fu nctio n a l testi ng

a r t ic u l a t i on

phys i c a l ex a mi n a t i on ,


E);f'rf'49··i§·'• Treat m e n t

of t he deltopec toral muscles d u ring isokinetic rotation a t the glenohumeral j oi n t , and the s i g n i fic a nce of th e se research fmdin gs , par tic u larly for s w i m mers I .


ind ica ted to S a l ly a n d her mother wh at I fel t was the

It seemed to me at this stage that any success w i t h

most ap pro pri ate c o u rse of treatment I cou ld o ffer. I

Sa lly wo u l d rely a s mu c h as any t h i n g on gaining t h e

reali s e d

con fidence of both Sally and her mother, Therefore,

from what had been offered by other hea lth pro fes

I expl ain e d what I considered to be S a lly s prob lem,

Sionals in whom they d id not


that as this wa s n ot substa ntia l ly d i fferent ­

h ave co n fi dence , it was

ind ic ati ng th a t sh e h a d hy permob ile shou lders and

i mpor t a n t that this app r o ac h was so l d very s tron gly

sc apu l ae with i na d equ ate muscular con trol for the

to co n vi n ce them that it was not sim p ly 'more of the

demands she p l aced on them . The maj o r ity of her p a i n

same ' . It was also i mpor t a n t t h a t a ny reh a b i li ta t i o n

w a s likely t o be rel ated to genera lized l ow g r a d e capsu­

prog ramme be a d a p ted to a regi men of swim tra i n i n g,




l a r inflammation from the conti n u a l ir ritation caused

as this was obv iou sly impor tan t to both S a l ly and my

by stress created by the high levels o f swimming.

c r e d ib ili ty I pO i n te d o u t that the next 4 weeks when

I bro u gh t the skeleton i nto the cu bicle and s howed

s h e was out of the water would be a n ideal time to


them where these structures were, t he reason why the

work hard on im p rov i n g her muscle functi on. Once

ro tator c u ff is wel l pos iti oned to fu nction as the pri­

swi mmi ng recommenced,

mary g leno h u m era l j o int st a bilizer and what was hap­

i n g coupled

pening with S al ly ' s scapulae when she loaded her

gramme through the wi n ter wou l d b e ad vanta geou s

s houlders. I t a l ked to them abou t core sta bili ty a nd the

ho pe fully putti n g her i n an opti m a l posi tion to re tu rn

find ings o f research u ndertaken by David et a \ .

( 2 000) ( 1 9 9 8 ) , d emo n strati n g consistent fir i n g

to fu ll training w i t h o u t p a i n in th e spri n g . I emph a­

and Ca rr et a \ .

sized th a t the primary respo n sibi l i ty for th e pro­

of the rotator c u lT a nd b iceps gro u p p r i o r to a c tiva t i on


g ran1ffi e wou l d rest with

Copyrighted Material

reduction in swim train­

with ti me spent on her rehabilitation pro­

S a l ly herself

and t h at




th erefore, S a Uy had to want to d o the programme for it to be success ful. I gave them the opportu n i ty to decide whether they wanted to try the prog ramme. Once they i ndicated that they did want to try, I spent some time teachi n g S ally rotator cuff activation with the d yn a mi c relocation m a noeuvre, so that before she left she was able to produce


relatively isolated rotator

c u lT co-contraction of both s h o ulders in thi s posi tion and hold it wh ile lifting and lowerin g her hand with her

arm in a supported position. I a lso ta u ght her simple scapul ar awareness strategies . with particular emphasis on scap u l ar d epression and retraction , as this move­

Fig. 1 1 . 5

ment was the one identified as least e ffective. Since

on fi rst assessment.

S a l l y s scapu l a r co ntrol i n fou r- p o i n t k n e e l i ng '

S a lly was only able to m a i n t a i n the contraction with­ out l oading, these movements were u ndertaken wi th­

when tested in s u p i n e . She was o n ly a b l e to m a i n t a i n

o u t ad ditional load . S he was encouraged to do these

t h e c o n tr a c t i o n a n d l i ft a n d lower o n e leg from crook

exercises at least once a day in a set exercise time and to

l y i ng. She was also ab le to maintain a TA c o ntraction

work on increasing awaren ess of shoulder and scapu­

during brid g i n g with seg m e n t a l l i fti n g a nd lower i n g ;

l ar stabil ization with movement during the d ay. The

t hese two exerc ises were al so add ed t o the pro­

a im o f this was to faci li ta t e activation of correct timing

g ramme. together w ith an ex p l a n ation o f how t h ey

of c ontraction i n these stabi lizers.

s ho u l d hel p her shoul der problem .

• Treat m e n t 2

• Treatm e n t 3

The next tre a tme n t took p l ace 1 week l a ter. At this

By t Ile third v i sit. S a ll y h ad m i n i m a l pain

t i me . S a l ly had been p a i n- free (she was not swim­

side of the quadrant. She was able to m a i n tain a rotator

m i ng) a nd both her rotator c u ff and sc apu l a r retrac­

c u ff dyn amic relocation contraction d u ri n g isol a ted


the low

tion con tractions were improved. The p a i n o n the low

glenohumeral j O i n t rota tions agai nst l i g h t theraband

s i d e o f t h e q u a d r a n t position was a lso less. She was

resistance i n approximate ly 100 deg rees of tlex i on .

able to

m a i n ta i n

the rotator c u ff contra c t i o n w h i l e

whi l e simultaneously mai ntaining


st able scapu l a .

l ift i n g her fo rearm o f f the s u p port. Awareness o f

Her abi l i ty t o stab i l ize her scapu l a i n fo u r-point kneel­

s c a p u l a r p o s i t ion d u r i ng PNF p a t t e r n s w a s a li ttle

ing was a lso i mproved. so that maintain i n g this posi­

improved . Importantly. i n review of the rati o n a l e fo r

tion d u ring PNF p attern m oveme n ts against theraband

t h i s a p p r o a c h to m a nageme n t . b o th Sal ly and her

resi sta nce with the oppos i te arm were included in her

mother appeared to h ave a good understa n d i n g o f

programme. Isolated l owe r trapezius exercises were

wha t wo u l d b e required and w hy. Assessment




replaced with fu nctional PNF scap u l ar diago n a l s also in

fo u r-p o i n t

against theraband . while m a in ta i n i n g the humera l

kneel i n g w a s u n d e r t a ke n . demons trati n g good ab i l i ty

head dynamic re location. A bdomi n al fu nction had

to i s o l a te scapu l a r protraction ( F i g . 1 1 . 5 ) but poor

improved considera bly. i n d icati n g that her poor contTol

e n d urance w h e n loaded by l i ft i n g one arm. d e mon­

on first testi ng was likely to be a res u l t of poor motor

s trated by w i n g i n g of t h e med i a l border of the

awareness/programmin g rather than true weakness .

scap u l a . Assessment o f isometric l ower and middle

At this poi nt. TA contro l during ro tary leg move­

trapezius fu nction revealed cons iderab l e weakness o f

ments in s u p i n e was assessed . as was glu tea l fu nction

lower trapeziu s . s u c h tha t she co u ld o n ly m a i n t a i n


on a stable TA contraction in prone. Appropriate

s t a b le scapula i n depression w i t h the arm supporte d

levels or exercise for both these fu nctions were a d d ed to

i n approx i m ately 1 2 0 deg rees glenohumer a l abduc­

the prog ramme. I also described how to make an exer­

tion and elbow flex i o n . In this positi o n . rotator cufr

cise bar to facilitate abdomi n a l fu nction with an exer­

co-contraction a n d h u mera l l ateral rotation c o u ld b e

cise colloq u i a lly know n as ' twisties · . as described by

a c h i e ved . T h i s exerc ise was added to her progra m me.

Peter Blanch. physiotherapist to t he Aus tra l i an Swim

Transversus abdominis ( TA l fu nction was a ls o poor

team at the Austra l i a n Institute of Sport ( F i g . J 1 . 6 ) .

Copyrighted Material


Fig. 1 1 .6

Fig. 1 1 . 7

T h e ' a b d o m i na l /tw i s t i e s b a r ' fo r fac i l i tating

Wa r m - u p exerc i s e with t h e r a b a n d i n a

exte r n a l o b l i q u e con tracti o n and body ro l l i n swi m m e rs

s i m u lated catch pOSition fo r t h e b u tte rfly stroke, in w h i c h

with s h o u l d e r p a i n . T h e twisties ba r consists of a b ro o m

S a l ly worked on s ett i ng the s c a p u l a e i n a n e u t r a l sta b l e

h a n d l e o f a p p ro x i mately 1 80 e m l e ngth, w i th b o l ts a n d r i ngs

pos i t i o n , relocating t h e head of h u m e r u s i n the g l e n O i d

at each e n d , each fa c i ng in o p p o s i te d i re c t i o n s . T h e ratu bing

a n d m a i n ta i n i ng c o n trol o f both w h i l e p u l l i n g aga i n s t t h e

of a p p ro p r iate stre ngth i s th e n atta c h e d to the b o l ts and

t h e ratu b i n g i n to t h e downsweep p a r t of the stroke.

co n n e c ted to s i m i l a r bolts o n the w a l l , s o that o n e i s p u l l i n g at r i g h t a n g l e s to the body p o s i t i o n b e h i n d the pati e n t and t h e other i n the s a m e d i re c t i o n fro m i n fro n t

Sa l ly three specific pr etr a i ning exerc i s e s : o n e aimed at

o f th e patient, t h u s p rov i d i n g a rotary res i s ta n c e . T h e

facilitat i ng rotator cufl' co-contraction d u r i n g swim­

pati e n t c a n t h e n l i n e th e i r t r u n k u p s o t h a t the resista n c e

ming. the second at facilitat i n g the combination of

wo rk i s p e rformed fro m neutral towa rds i n n e r r a n g e o r

rota tor cuff co-contraction a n d sc a p ul a r control

fro m outer r a n g e towards m i d - range. Fo r s w i m m e r s , the

( F i g . 1 1 . 7) and the third at enc o u ra g i n g S a lly to lead

parti c u l a r benefit of this exe rcise i s that they can l e a r n to i n i tiate the rotation fro m th e p e l v i s a n d t h e n i n tegrate the t r u n k m ove m e n t, t h u s m i m i c k i ng the action req u i red a t

her body roll from the hips by u sing her o b l i q u e abdomin al m u s c l e s , fa ci l i t at i ng a stretch-shorteni ng contraction in these m u scles and thus redu ci ng the

the catch p h a s e of t h e sw i m s t r o k e . M o re c h a l l e n g i ng

l o a d on her s h o u lders . I checked the remainder of the

rotational load can be p ro v i d e d spec ifica l l y fo r swi m m e rs with t h e bar ove rhead . M ov e m e n t is s ti l l i n i tiated fro m

exercise progra mme and modified it a p propri a tely. We

the p e l v i s , b u t the longer lever p rovided by h av i ng the b a r

decided to review the s i tu ation in 2 w e e k s to evaluate

ove rhead p rovides m o re c h a l l enge t o th e a b d o m i n a l s i n a

the effect of these s pecific pretr a i ning exercises on her

p o s i t i o n s i m i l a r to t h a t re q u i red at t h e catch phase, a l b e i t

return to s w i mmin g .

w i t h both a r m s ove r h ead not o n e .

A t t h i s point, r decided t h a t I should try t o m ake the programme more interesting for a 1 6 - year-old girl. I decided to try to incorporate some S w i s s b a ll

• Treatment 4 Fo lloWing this v i s i t

work and spen t some time working out ways in which 3 - week b reak in treatment was

I cou ld ad a pt her exercises to be done on the ba l l .

prov ide d . d u ri n g which time S a l ly began swimming

My m a i n aims at t h i s stage were to improve her


tra in i n g a g a i n . A t the next visi t , she indicated that

abdom i n a l a nd p elv ic/hip strength a nd control as

she had less t i m e for the exercises a nd that she still

q u ic kly a s pos si b le to tr y to reduce the load th r ough

had some pain during s w i m m i n g , but it seemed to be

her shou lders, wh i le conti n u i ng to work on her

less . She was on ly swim ming t hree mor nin g s a week

shou lder a n d sc a p u l a r stability, which I a n ticlpa ted

at t h i s stage. Her quadra nt assessment indicated


would take l o nger to i mprove, pa rticula rly si nce

s li g ht i ncrease in p a i n with the same d eg ree of resist­

she was s w imming. Therefore, her abdom i n a l and

ance a pplie d to the movement. Assessment of abdom­

pelvic work could be quickly progressed onto the ball


a nd

gl u te al

fu nction demonstrated


and the u pper q u a r ter exercises made more chal­

imp rovement. whi le i m prov eme n t in s capu l a r a nd

lenging by d o i ng them on the unstable surface pro­

ro tator cu rl' fu ncti on

v i ded by the b a l l . The i n t entio n was to do th is at the


l ess appa rent. As a resu l t of

the retu r n to the water. 1 spent some t i m e teac h i n g

next v i s i t .

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• Treat m e nt


prog ramme cer t a i n ly seemed to h ave been effective.

At this next v i sit. S a l ly i n dicated t h a t s h e had done

fa irly

as S a l ly reported r ed uced pain with s w i m m i n g and


more awareness of her scap u l ar posi tion and a sense

th o u g h u s u ally before she left home to go to the pool

o f control i n her s houlders. She was al so more a ware


pretra i n i n g


rather than a t the pool itsel f. a s much so that she d id

of her body rol l . t h ou g h could not see that it made

not st a n d out fro m the crowd as d i fficulty comple t i n g

much d i rference to the l o a d thro u g h her shou lders .

t h e m pools ide. W h i l e this w a s not i d e a l . the time

She was not swimming compe titively at this stage. so

d i fference was relatively small and I decided t ha t

a ny effect on her swim times by her concentration o n

t h e faci litation wo u l d probably sti l l be va l u able. The

t h e s e strategies c o u l d n o t ye t be deter m i n e d .

REASO N I N G D I SC U SS I O N A N D C L I N I C AL REASO N I N G C O M M E N TA RY From yo u r c o m m ents earlier a b o u t the

This perception had the potential to provide

i m p o rta n c e of gai n i ng t h e confi d e n c e of Sally and

positive outcome on the basis of placebo. I feel it is impor­

degre e of

h e r m o t h e r a n d the t i m e yo u gave to exp l a i n i ng

tant to build on such advan tages. so that the time spen t


a n d ed ucating them on both the p ro b l e m a n d its

on explanation of the problem was in tended to reinforce

ma nageme nt, you c l e a r l y place a lot of em p h a s i s

the 'shou lder ( a n d swimm i n g ) exper t' perceptio n . This

o n e d u cati o n . C o u l d you c o m m e n t o n yo u r

also allowed me to present a potential programme to them that was n o t u n l i ke what they had been exposed

reaso n i ng b e h i n d this ?

to before w i t h o u t elic i t i n g an i mmed i a te ' more of the

• C l i n i cian's an swe r

same' reactio n . t h u s e n h a n C i n g com p l i a n ce

My dec i s i o n to spend a c o n s i dera ble amo u n t of time

impor tant for self-ma n ageme nt. If S a l ly could u n der­

Patient u n d ersta n ding of


the problem



on explanation a n d e d u c ation was based o n the pri n ­

s t a n d t h a t swimm i n g wh i l e she had poor control of

c iple that p atient m a n a geme n t should be a shared

her scapul a r and gle n o h u meral hypermobility was

respon s i b i l i ty a n d that i t will be more s u ccessful if the

l ikely to exacerbate her symptoms , she was more

patient h a s been

l ikely to a g ree to a mod ified tra i n i ng prog ramme tha n


ac tive contri b u tor to the d eve lop­

ment of the man agement p l a n This convic tion is s u p­

if I had sim ply t o l d h e r s h e must stay o u t of t h e water.

ported by the observation that m a ny patients w i th

S i m i l arly. such understanding mea nt t h a t she was

chro n i c problems te l l stories of m a n agement imposed

highly motivated to i mprove her muscle control so


on them or management that they d o not fu lly under­

that she could retu r n to s w i m m i n g as soon

stand. so that they feel they lose control of the situatio n .

sible. S a l ly was fa r less l ike l y to do someth i n g sil ly that



Empowerment seems t o be a n impor t a n t component

wo u l d exacerbate the pro b l em if she understood the

to a ny s u ccessful m a n a ge me n t strategy. W i th S ally's

reasons why she should behave as s u gges te d


p articular s i t uatio n . I hypothesized that a lack of

Part of the proposed programme included increas­

empower ment appeared to be one fa ctor that was

ing Sal ly ' s awareness of body roll and kick, with t he

common to mos t of the strategies attempted . It seemed

need to improve her strength and awareness of abdom­

t h at nobody had ever explained to S a l ly or her mother

inal and pelvic m u scle fu nction ; this was in tended to

what the likely mec h a nism of symptom production

reduce the l oad on her shoulders. Without an adequ ate

was a n d . th erefore. why any par ticular approach to

u nderstanding of her problem and the mecha n.ics of

m a n agemen t should be und ertake n . If the therapists

swimming. it is u n l il<ely that S a l ly wou ld h ave seen the

had . in fact. exp l a i n ed these points . n e i ther S a l ly nor

pOint o f a progranlffi e a i med a t abdominal and gl u teal

her m o ther appeared to h ave grasped the concept.

strengthenin g and would not have compl ied with it.

I recognized that r h a d an i nitial advantage with Sally

A fu rther point that was i mpor tant to m a ke to S a l ly

and her mother as r h ad been recommended to them as

a n d her mo ther was t h a t a p ro g r a mme such as that

a 'shoulder expert' . so that they had come with

s u ggested had the pote n t i a l to slow S a l ly ' s race t i m e s


posi tive

perception of my abili ly-whether wel l founded or not !


at least i n the short ter m . w h i l e she was learning the

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1 1 B I LAT E R A L S H O U L D E R PA I N I N A 1 6 -YEA R - O L D L O N G - D I STA N C E SWI M M E R

stabi l ization s trategies i n the water. As with a ny new tec h n i q ue. its mastery t a ke s some time and perform­ a nce is usua l ly reduced d u r i n g the m a s tery p h ase. Sal ly had to be prepa red to accept t h i s a n d work through it. However. this was not an issue for S a l ly. as her times for the season j u s t completed had been s low anyway as a res u l t of the shou lder pain. The p o ten t i a l for improvement was s u fllcient t o ma ke her prepared to try the prog ramme. We also had the advantage that she had come to see me in the q u ieter seaso n . so that a short-term red u c tion in times w a s n o t as d i sastro us a s i t m i g h t h ave b e e n a t the b egi n n i ng o f a new seaso n .

fit wel l with the attri b u tes of ex p e r t manual therapi sts



Jensen et a l . ( 1 9 9 9 ) .

Reassess ment . a form o f hypothesis tes t i n g a n d

mediu m for rellection. a l s o features stron g ly i n the c l i n ician s man agement. Importantly. the reassess­ '


here include patient u ndersta n d i n g as well as

physical joint a n d mu s c le

co n tr o l



d e al of emphasis on education and ex pla nation . yet their reassessments may only focus on physical signs. In C h apter 1 . teaching was presen ted as


focus of c l i n i c a l reasoning. If p a ti en t ( a n d sup­ porters) u nderst a n d i n g is judged to

• C l i n i cal

impai r m e nt s/

dysfullction s . M a n u a.l th e r a pi s t s often p l ace




problem. as in this case. then reassessment of

reaso n i n g commentary


n ation s provided is essen tial to ensure learning has

t hrough t h e c l i n i c i a n ' s man agemen t d escribed and

st ill j udged to be fau l ty. fu rt her exploration for the basis of t heir views (an importa n t step for some patien t s to revise their u nderstanding/beliefs) and/or al tered stra te­

discussed above. These d i mensions of manageme nt

gies of explanation may be required .

occurre d . If their understanding was

Explan ation/teac h i ng. patien t u n derstanding ( cog­

nitive and motor ) . empowerment, shared d e cis ion m a k i n g and sel f-man agement are all e vid e n t

Reassess m e n t of a l l dy na m ic features ind icated con­ tinued improvement. with the least i mprovemen t i n the rotator c u ff fu nction-predictable a s these are the muscles most i n h ibited by the shou lder p ai n . We trans­ ferred abdominal and lower limb work onto the SwiSS ball as pla n n e d . with Sally doi n g a series of exerc ises aimed


improv ing



con trol

a nd

strength avai lable for kicking. One i nvol ved ma intain


i n g control of her tTu nk and pel vic position while b a l ­ ancing on her thoracic s p i n e o n t h e b a ll. [n th i s posi tion she d id alte r n a te h i p flexion. fol lowed by knee exte n s i o n . trying to repl icate the muscle activi ty a nd movement

req uired



u p beat




1 1 . 8 a ) . A second exercise u nder taken i n prone

( Fi g .

lnvolved Sal ly bal anCing through her hands. m a intain­ ing


stable glenoh umeral j oint an d scapula. with the

ball u nder her abd omen . From this position, with her toes assisting the b a lance, S a lly maintained


TA con­

traction while a lternately lifting one leg from the hip s . ensuring t h a t s h e used predomi n a n tly gl u te a l s t o per­ form this action ( F i g . 11 . 8 b) . As her ba lance improved

Fig. 1 1 . 8

Faci l i tated k i c k i ng fu nction on a Swiss ball

while m a i n ta i n i ng abd o m i n a l contro l . (a) In supine over the ball, Sally was req u i red to m a i nta i n h e r b a l a n c e t h rough o n e l eg a n d her tru n k, e n s u ring a p p ropri ate a b d o m i n a l and g l u teal activati o n w h i l e go ing t h rough the kicking motion with the othe r l eg, trying to rep l i cate the u p b eat action of the k i c k . (b) In p rone ove r the bal l . Sal l y was req u i red to m a i n ta i n an appropriate abdom i n a l contraction a n d

with both these exercises. S o l ly increased the rate of t h e

ba l a n c e , assi sted b y h e r weight on o n e t o e , w h i l e s h e

' Idck' . t h u s su bstantially in creasing t h e l o a d required of

worked on the k i c k i n g a c t i o n w i t h the oth e r leg. e n s u ring


tru nk stabil izers. This series of exercises was fu n and it seemed like Sally would be

and ch allengi ng to d o

that s h e e m p haSized a relatively straight l eg a n d g l u teal fu nction i n p e rfo r m i n g t h i s acti o n .

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continue to do her fa c i l itation exercises pri or to trai n i n g Sally ' s mother indicated that her coach was .

happy with this arran gement. I asked about attend ing a training session a n d ta lk in g to the coac h , but we quic kly real ised th a t t h is was not

a pra cti c a l option at

the time as trai ning was at 5 a . m .

• Treatm e n t 6 The next v isit took place 2 weeks later. S al l y a

little despond ent,


i n d ic a tin g that imp rovement

seemed to have pl a te a ued, with some return of her shoulder pai n d uri n g swimm i n g . She had i n creased the distance travel led du ring each session and her swi m tr a in i n g to 5 d ays a w e ek . Sally certainly could see some i m prove ment i n her shou lder control and aware ness while swi mming, and her use of body rol l

a nd kick, but was disap pointed because of th e return Fig. 1 1 . 9

Sid e-ly i ng fac i litation of dynamic control of

of shoulder pain , Her quadrant position , whi c h had

scap u lar a n d glenoh u m e ral positions at the catch phase of

been p a infu l e a rly on, was certain ly more p a i n fu l

the swi m stroke. Sally is using the therapis t's body to

than the last time it was assessed , w ith a slightly

si mul ate the water in the catch position , while th e

spongy end-fee l . There also a ppeared to be some sub­

therapist applies tacti le stimulation to encourage, fir st, scapular setting in a n eutral position and then, rotato r cuff relocation prior to Sa l ly p u l l ing the ar m down through the downsweep action of th e swim stro ke; this is similar to h e r warm-up pool-s i d e exerc i s e .

tle swelli ng in the su bacromial/su perior capsular region of her should er. Isometric resisted rotati ons in 90 deg rees of nexion n ow reprod u ced the same pai n as provoked with the qu a dr a n t posi tion . Clearly the additional swimming was aggravating

enthusiastic t o contin ue t h e m a t home. This she was to

the shoulder problem and Sally's rotator cuff and

do in addition to the twisties exercises an d the ro tat or

scapu l ar control was n ot yet su rficient to cope wit h the

cu ff a nd scapul ar stabil izing work.

ex tra load , I pointed this out to her and asked how

In a d d i t i on, I spent some time worki n g with Sall y in

much o f a probl em it wou ld be to return to the regi­

side lyin g usi ng tactile facilitati on and manual resist­

men of 3 days swimming. She was rel uctan t to do this

ance to improve her rotator c u ff and scapular stabil­

as winter pennant champi onships were on ly 3 weeks

izati on fur ther, i nitially at the catch phase (Fig. 1 1 . 9 )

away and she wa s keen to compete wel l in these. I indi­

and later at t h e IInal stroke of the pull-through phase

cated that I fe l t that this wou ld slow do wn her progress


of her freestyle stroke . This manoeuvre w a s si milar to

and that, i f the champi onsh i ps were important. sh e

the pretrainin g facilitation exercise b u t was enhanced

would have to accept the slower rate of progress and

by the manua l contact. D u r i n g these exercises she was

do more to red uce i n flammation in her shou ld ers fol­

encouraged to maintai n the TA c ontraction.

lowing each sw i m session . I suggested gen t l e th rou gh­

I asked Sally and her mother whether they were

range m ovement with rotator c u ff con trol w h i le i n

hap py with the progress to date and whether they had

the warmth o f a shower immed iately after tr a i n in g fol­

any particu lar questions; they seemed enth usiastic

lowed by ice massage to the sub-acromial space/rotator


ab out how thin gs were going. We discussed maintain­

inter val area, with a fu r ther brief b u t deliberate rota­

ing a reaJistic sched ule for Sally w i t h i n the con text of

tor cu ff facil itation session a fter the ice . I also su g­

her sch oolwork and swimming req u irements . It was

gested that she increase her rotator cuff stabilizi n g

deci ded that SaJly should do one exercise session per

work d u r i n g her exercise sessions, aiming t o i n crease

day worki n g s peciftc a lly on the tasks set. In addition,

the rate of i mprovement in this fu ncti o n .

she wou ld work on

a repetition /awareness prog ramme

I n add ition , treatment t h a t day incl uded gentle

198 6 : Mai tland ,

d uring the d ay to facili tate cor rect motor programming

mobilization (Grad e rV---) (Magarey,

of scapu l ar and g l enohu m eral stabil izalion and would

1 9 9 1 ) of her glenohu meral j O i n t into the q uadra n l

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11 BI LAT E RA L S H O U L D E R PA I N I N A 1 6 -Y EA R - O L D LO N G - D I STA N C E SWI M M E R

posi tion . w ith G ra de IV-- s u ba crom ial di s lTacti o n

pe rfo rmed short of pai n . foU owed by Gra d e III-- m o b il­ ization in the same directi o n . Pain on tes ting of the

qu a dr a n t and on isometric rotator c u ff tes tin g was

red uced fo l l o w i ng the mobi l iz a ti o n and S a l l y was ab le to generate a dynamic rel o cati o n contraction more stron g l y in the 90 degree 11ex ion position . Mo re side­

lyin g facilitation work on rotator cuff and sca p u l ar stab i l izing was then added . as at the l a st tre a tment . Sally ' s mother phone d a week later to say that the s hou lder pain during swimm ing w a s less and that the pain she did have was reduced co n siderably fo l l owin g the post-training regimen. S a l ly fel t

m o re

co n l'ide n t that

she would be ab le to co ntrol the pain better and. there­ fore. the c o ncern ex pres sed at the last visi t was al lev i­ ated somewhat. I s u ggested to Sal ly ' s mother that they continue to work on the s ame re g imen . with appropri­ ate progressions until after the w inter pennant competi­

F i g . 11.10

tion unless they had further clifl'iculties . I also sugges ted

weighted ball in a simulated catch position while balancing

that SaUy take her theratu bin g to the p oo l and do her ro tator

Mini- plyometric throwing exercise with a

on the Swiss ball.

c u ff/s c apul a r facilitation exercise immediately

prior to entering the water and again three times durin g

d i fferent from the res t of the sq u ad . However. she

the tr a ini ng session.

fo und that the regimen reduced the a m ou n t of pain

to try t o maintain the pre­

activation throu g h o u t the training sess i o n .

during the session and also seemed to i mprove h er stroke an d so was h appy to c o n t inue with i t .

• Treat m e n t

Her quadra nt position was less pa i n ful . the s u b ­


acromial area less swo llen, and h e r rotator cuff a nd

Th ree weeks later fo l lowing the c h ampions hips, at

scapular stab i l izin g contractions

wh ic h Sal ly ' s limes were imp roved , both Sally a n d her

more than I might h ave anti c ipated based o n the ra te


im proved ­

mother seemed much more reassured and enthusias­

of progress to da te . Tre a tment consisted of more r ota­

tic about her progress . r p o inted o u t to them that S a Uy

tor cu rr and scapular sta b ilizin g work in d i fferent pos­

was not ideally b u il t for the load she wa nted to put on

itions and showing S a lly how she c ould work on this

that she was likely to h ave to pu t up with

with some ' mi n i-plyo metric' drills to m ake her exercise

s o m e shou lder pa i n if she wanted to c o n ti nue to train

sessions more interestin g . Th i s was achieved by m a i n­

hersel f

a nd

hard and aspire to great ach ievements in swimming.

taining the stabilizing c o ntra c t ions wh i le th ro win g a

However. s h e had shown herself that she could minim­

ten n i s ball a shor t dista nce to a wa ll, ca tch in g it o n

ize thi s with app ropria te work o n gene r al s trengt h and

return and throwin g it again as qu ic kly as poss i b le.

technique a n d faci litation of her rotator c u ff/scapular

This was done with Sally 's arm in a p O Sit i on of approx i­

stabil izers . A lso, when the p a i n was present she cou ld

mately 1 2 0 de g ree s of flexion in the p l a n e of the

reduce it with the pretrai n i n g and post-train ing regi­

scapula . She was able to ach ieve this quite re ad i ly.

men we had i n s ti tuted . T h is empowerment and con­

even as the speed of throw and catch was i ncreased .

trol over the pa i n seem ed to h ave made a profo u nd

I showed her how to prog ress this exercise

difference to Sal ly. who was much hap p ier and outgo­

main tainin g the control. Later, S al l y pr o g res sed to use

wh i l e


ing at this visit than at any other time. She seemed no

of a small wei g h ted b a l l . either in the same way or in

l on ger scared of her shoulder pain a n d n o l o n ger saw

c o njuncti o n with trunk stab i l iza tion o n the S wiss ball

(Fig. 1 1 . 1 0 ) . S he also be g a n some plyom etr ic wa l l

it as the end of her swimming career.

When I asked


effect intermitten t exer c ising

p u s h -ups with her arms in different posi tions of Hex­

thro ug h the training session had had on her pain both

i o n , maintaining rotator c u ff control while wo rking

d u ring an d a fter t ra i n i n g , Sal ly ind icated that she had

th e sca p ular muscles (Kib ler, 1 9 9 8 ; Wilk and Arri go , 1 9 9 3 ; Wilk e t a l . . 1 9 9 3 : WW< and Vo i g ht. 1 9 9 4 ) .

initia l l y been reluctant to do it as i t wo uld make her

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REAS O N I N G D I S C U S S I O N A N D C L I N I CA L R EASO N I N G C O M M E N TA RY C o u l d yo u c o m m e n t on th e ro l e of p a l l i ative

of the pain and s trategies that can be employed , both by

treatm ent, s u c h as the m o b i l i zati o n s yo u a d d e d ,

the therapist and the athlete, to reduce or elimin ate the

i n t h e bro a d e r m a nage m e n t of a pre d o m i n a n tly

pain. The therapist should also point out that hi gh­

muscle c o n tro l p ro b l e m ?

performance ath letic endeavo ur often places forces o n struclures that are beyond our ability t o control com­ pletely. This is particul arly the case if the athlete's bio­

• C l i n i cian's answe r

mec hanical mal<e-up is not ideal for the particular

I n i t i a l ly, Sally ' s prese n tation i n d i c a ted very l i ttle p a i n w i t h a ny active or passive m ovemen t , but a n excessive r a n ge of movement a n d poor m uscle contro l . At t h a t t i m e , e m p h a s i s o n a d d ressing t h i s c o n t r i b u ti n g fa ctor was c l early th e highest pri ori ty. My hypothesis at the time was t h a t there was l i ttle i n tri nsic tissue d a mage and wh a t was present re l a ted more to conti n u a l irri­ tation than true pathol ogy. However. a t the poi n t w h e r e pall iative m o b i l i z a t i o n was added t o t h e treat­ men t, there was ev idence o f more obviou s provo c a­ tion of symptoms and some physic a l c h a n ges a round t h e s h o u ld er. Con tinued work w i t h the muscle con­ trol approach and a reduction in s w i m m i n g wou ld h ave a l l owed this aggravation

s w i m m i n g a nd not red uce the i n tensity of her train­ i n g . S h ort-term bene fi t could be gained fro m pallia­ tive tre a tme n t a im e d at red u c i n g the i nfl a mmation i n subacrom ial/superior

muscle performance and control arou n d her shoulders shou ld reduce her pain and , therefore. i mprove her swimmi ng, it was important that she understood that the repetitive load with swimmi n g might have been more tha n her biomechanical mal<e-up could cope with i n the long term. The muscles si mply may not h ave been able to work sufficien tly to stabi lize her shoulders fully. Providing her with immediate palliative strategies to reduce symptoms that were provoked gave her more confidence to work with some d iscomfort. rather than to let the discomior t overpower her.

to settle i n time .

However, it was i mportant to S a l ly at t h a t time to keep


sport. as was the case w i th Sa lly with her hypermobile shoulders. While a programme designed to improve

capsu l ar

area ,


reducing her p a i n , so that s h e could continue swim­ mi n g . While this tre a t m e n t was recognized as h av i n g n o l o n g-term e ffect o n h e r problem , i t did provide t h e necessary immedia te p a i n relief a n d al so al lowed

What was yo u r c l i n i cal a n d p hYS i o l ogical rati o n a l e fo r i n co rporati ng p lyometric exerci ses i nto h e r p rogra m m e when swi m m i ng does not req u i re the q u i c k ecce n t r i c-con centric change over that occurs with th rowi ng?

• C l i n i c i an 's answer There is a small plyometric compon e n t to swimming

S a lly to see that she s h o u l d b e able to control her p a i n

that is bei n g i ncreasi n gly recogn ized by swimming

herself with s i milar measures if she fo und t h a t t h e

coaches and rel ated health practitioners . Immediately fol l o w i n g hand entry, the arm reac h es as far forwa rd

lon g tra i n i n g aggrava ted h e r symptoms. This episode also gave me the opportunity to provide

as possible, p lacing a stretch o n the oblique abdom­

S ally with further i nsight into the requirements of elite

inals, the scap u l ar retractors and glenohu meral medial

sports performance. If swimming continued to cause

rotator s . This stretch provides some stori ng of elastic

pain in her shoulders, she would be able to understand

energy i n the series elastic components of the rele­

why and be able to come to terms with it and not neces­

vant muscles (Wilk a n d A r rigo, 1 9 9 3 : Wilk et ai. ,

sarily ass ume t h a t the therapy provided was of no value.

1 9 9 3 ; W i lk a n d Vo ight, 1 9 9 4 ) . thereby e n h a n c i ng

A common feature of high-level athletic per formance is

the concentric contraction requ ired at catch. Recent

that athletes live and perform with some level of pain .

adva nces in tec h n iq ue emphasize i n i t i a t i n g the catch

To an athlete, the value of the athletic performance

from the pelvis, similar to the i ni t i a t i o n of the fo rward

is greater than the pain and the potential damage

movement of a throw, to generate more power through

inllicted . When a yo u n g athlete attends for treatmen t of

the powerfu l tru n k rotators rather than relying o n ly

a painfu l problem for the fIrst time, i t is the therapist's

on the smaller, less-efficient shoulder girdle a nd gleno­

responsibility to expl ain the mechanisms for production

h umeral muscles. The side-lying PNF procedu res

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11 B I LAT E R A L S H O U L D E R PA I N I N A 1 6- Y E A R - O L D L O N G - D I STA N C E SWI M M E R

described above p l a ced S a l ly ' s trunk a n d shoulder g i r­ d le in a s i m i l a r posi tion to that at the c atch point i n the swim cycle. the r eby attempting t o repl i cate the muscle load . enh ance t h e co n tr ol req u i r ed in t his position a n d create a small stretch-shorten i n g com­ ponent. However. man u a l handl i n g and d ry land exercise cannot fu l ly repl icate the muscle r equire ­ m e n ts i n the water. and tra i n i ng of the musc les in a stre tch - sho r te n i n g cycle in p os i t ions similar to those requ ired in the catch phase w as i nc l u d e d t o repl i ca te ( as closely as was p ossi b le on dry la n d) t h e ac t i o n t ha t was requi red of these muscles at catch . Use of a throw ­ catch rou t i n e also e ncouraged a q u icker changeover from eccentric to conce n tric contraction t h a n is n o r m al ly p ossibl e i n the water. Phy s i ologic a l evide nce (Kom i . 1 9 8 6 ) also indi ca tes that eccentric m u s c le work is more energy efficient than concentric. so that g reater force can be created for the same amount of work. Therefore. if a patient has poor endurance. wo rk i ng eccen t rically should allow tolerance of longer workouts w i th the p o ten t ial for faster improvement (Bennett a n d Marcus. 1 9 9 4 ) . I n additio n . gai ns from eccentric s tr ength tra i n i n g a r e g reater than those from e q u iva l e n t concentric training. with re d u c t io n of oxyge n c o n sum p ti on d ur i ng eccentric a c t i v i ty indicating imp r oved n e u r a l coordination ( P r i d e n e t a I . . 1 9 8 3 ) . Therefore. the inclusion of eccentric wo rk i n Sally ' s programme was j us t i fi e d .


G iven Sal ly's ove ra l l pres e n tati o n , i n c l u d i ng h e r u n i q u e ' pai n experience' a n d res p o n s e t o yo u r m a n age m e n t th us far, what we re yo u r tho ughts rega rd i n g prog n o s i s . In answe r i n g this cou l d yo u h i gh l ight those featu res of h e r p res entati o n that you fe l t s u p ported a positive p rogn o s i s a n d t h o s e s u p porting a n egative p rognos i s ?

• C l i n i c i an 's an swe r My t ho u ghts reg a rdi ng prognosis at this point were very posi tive in the short term-more so than r had exp e c te d when we star ted out. Sa lly had been very compliant with her progra mme: her understanding o f the problem and the requirements to address it were sou nd . S he had de m o n s trat e d herse lf to be far more assertive and enthusiastic about her swimming than first appeared , and the response to the manage­ m ent programme had been very good so far. Sally appeared to h ave little i ntrinsic pa t hology in her

shoulders: her basic s w imm i ng tech n i que was sou n d . as evidenced b y h e r success prior t o t h e development of the shoulder proble m . and her motivation to s u c­ ceed was very hig h. She also had a very suppor tive a nd stable family and all the p ri v i leges that go w i t h a n a ffl ue n t lifestyle: opportu n ities t o t ra i n a n d compete a t w ha t ever level he r ta len t took her t o . the safety and security o f good frie n ds . and the l i fe ex pe r i e n c es pro­ vided by an e x cl u s i ve private schoo l . The questions raised earlier a b o u t a ' p u shy ' mother were not sup­ p or t e d d u ring the m a nagement pe r io d : her mother was shown to be compassionate and concerned but n o t overbear i n g . Her domination of the e a r ly sessi o n s was more re lated to S a lly ' s teenage s hyness a n d . there­ fore. u n w i l l i n gness to speak for herself than a ny th i n g else. A s S a l ly b ecame more confident w i t h me a n d happy w i t h t h e progress. h e r o w n pe r so n a l i ty c a m e to the fo re and her mother's d o m i n a n c e reced ed . There had been n o s u p p o r t for the hy potheses related to pos­ sible central mechan isms considered i n i t ia lly a n d little t o suppo rt t h e a ffective obstacles identifi ed a s p oss i ble . However. there were some features t h a t did n o t s u ppor t such a positive prog nosis. par t icu l a r ly i f a long-term view was take n . The m a i n one was S ally 's intrinsic hyper m obi l i ty. Such hype r mob il i ty meant that he r shoulders would a l ways be d is a dva n t a g e d when she swam comp a re d w i t h a s w i mm e r of simi l ar ability with less-mobile shoulders. She was u n l i k ely to be able to generate the same levels o f power thro u g h her shoulders as the less-mobile swimmer. thus redu­ cing her c h ance of achiev i n g the fa s t times necessary to co mpete a t the top level. If S ally wa n ted to achieve c lose to those times she wo u ld be required to contin u e w i t h a maintenance programme of scapu la r a nd g l e n o h u m e r a l s t abil izi ng tra i ni ng thr o u ghout her swi m m i n g career. Even w i th the d i scipl i n e req u ired to maintain the tra in i n g necessary to compete at elite level. co n tinue d comp l i a nce wi t h t he stabilizi n g pro­ gra mme may n ot be as good. with the pote n tial for exacerbati o n of her symp t oms . There is a high incidence of shou l der pro b l ems i n eli t e swimmers res u l t i n g from the highly repetitive n a ture of the sport a n d the long d i s ta n ces s w u m in trai n i n g by these athletes. Hypermobile shoulders. s ubjected to a h i ghly repetitive l o a d . a re l ikely to d eveLo p i ntrinsic wear and tear p athology over ti me. even i f their muscle con trol is maintained a t an opti­ m a l leve l . Superior labral damage. fro m the repet i t i ve shearing at the catch phase. a n d a nterior l ab r a l

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damage . rrom compress ion duri n g the pull th r ough ph a se or the stroke, are l ike ly to be coupled with ge n­ e r a l capsular irritation. The muscle co ntrol requ i red i n a hypermobi l e shou lder is greater t h a n t ha t in a

s hould er with less mob ility.

Aga i n , over ti me this may .

lead to we ar and tea r pa thology withi n the rotator cu rr.



de ge n erative cha nges .

T he

anatomica l pla cemen t of t h e se m u scles a l s o mak e s them v u lnerable to ou ts i de i n fluences in the presence or poor control. With fa ti g ue of the rota tor culT a nd hypermobility or the s houlder the likelihood of develo p­ ,

ing subacromial or su bcoracoid i mpingement is h i g h a s a resu lt o f l oss of centr i n g o r t he humeral h e a d . w ith rotator cuff teari n g

associated with fr i c ti o n

traum a from the impin gement. T hererore, the long­ ter m prog nos is for S a l ly. if s h e c o n t i n ues to swim , is not as po s itive as the s hor t er term -


evidence beh i nd each p a i n mec h a n ism . s o u r c e a n d contri b u t i n g fac t or co n si dcred )


is s ues

contex t u a J


beliefs/ex pectat ions, perso n a l go a l s . co m mo n for



status, I t is

etc. ) .

Ill a n u a l t h era pists to t a ke

ei ther/or appro a c h . appro a c h

t he asso­

( psyc hosoci a l

recog nized can

impo r t a n t .



m ovem e n t treatment is

Passive mobi l ization


whereby once a dy namic passive

l o n ger e v e n considered .

b e a n effec tive a d j u n c t to

tre at p a i n a n d also c a n improve mu scle fu n c t i o n /

m o t o r con t rol



relier of

the i n h i b i tory

effect or pain on muscle fu n c t i o n . In this case. wh i le recognizing t h at passive trea t m e n t

woul d

not have a lon g-term effect on S a l ly' s problem. the cl i n ic i an j udiciously used passive mobilization

means to identi fy

as a

provide immed i a te pain rel ief a n d to

m e a s ur e s

t he patient could

u se

hersel f


h e r own fu t u re self- m a n a geme n t. The

• C l i n ical


i n i ci a n s '

progn ostic


is bot h

broad and rea l istic in its consideratio n s . The

reaso n i n g c o m m e ntary

c is e of


identifying posit ive a nd negat ive prognostic

be very u sefu l to (�lc i l i t a t e therapis t s ' rel1ection s . The pat ient 's im med iate pa i n

The c l i nician's a n s wer on the role of pallia tive

i ndicators ca n

treatment i n m a n a gement h i g h l i g h ts a d i ffic u l t d ec i si on ma n u a l th era p i sts r e g u l a rly face. t h a t is. should treat ment be d ir e cted at a hypothesized source or the symptoms or at a poten tial con­


tions are not rea l ised . a ret rospec tive cri tique of

and fu nctional status a n d t h e broader contex1 u a l fa c tors must all be taken into accou n t . When pred ic­


tribu t i n g factor. Even when i t i s clear that both an:.

what was j u dged positive and negat ive.

necessa ry.


other prev iously less -considered factors. can assist

to t reat

to rol low. I n

a decision is sti ll re qu i r e d first. There is no simple rule



t herapists


re c ogn i z e where they

wel l




u nderemphasized or perh aps CO I11-

t h e end. as evidenced b y the clinici a n ' s reason i n g


here, t h e decision m u s t b e based on t h e wei ghti n g

pletely d ism issed as not relev a nt d ifferent aspec ts of



patient's c linical


( s trength or


the patient's presentat ion and pain ex perience .

reduced quicldy


she did not do the s pecific exercises

a imed at its f a cilitation She wa s h appy to c ontinue with .

Sally continued with t h is programme for sever al weeks,

this regimen for an extended perio d with the arrange­

and she now u nd e rs tood how to progress it appropri­

ment that she would phone for a further appoi n tmen t if


ately. She continued to get some shou lder pain with

she wanted some more ideas for exercise progression . ir

swimm i ng. par t ic u larly when she increased distance or

she felt she needed manu al racili tation to improve her

nu mber of sessions, but over the remainder of the \vll ­

s houl d er function,

ter she found an opti m al training regimen ( i ncludin g

sized that I co n sidered she would need to con tinue spe­

sessions of


exercises) that allowed her swim­

ming to continue to improve without si g nifican t exacer­ bation of the

s houl d er

pain. She cer tain ly fouod that

or if she had

cifiC facili ta tion activities


any question s I empha­ .

long as she con tinued

swimmin g, and the commi tment to these would need to be propor tio nal to the amount of swim lTaining. as s he

she needed to keep up the exercise sessions and the facU­

had already shown that the improvements ga ined were

itation exercises during training or she quickly devel­


oped pain again . Sally also found that her awareness of

her to continue with the tr unk stabiliza tion and to work

pre activation and h er functional rotator cuff strength

hard on kicking s trengt h and technique with her coach


main tained withou t continued work. I e ncour age d

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1 1 B I LAT E RA L S H O U L D E R PA I N IN A 1 6 - Y EA R - O L D L O N G - D I STA N C E SWI M M E R

from some s h ou lder p a i n with her swimming. but she

t o lighten the load through her shou l ders a s much as was

had fo u n d ways in whic h s he could c o n trol that p a i n

possi ble.

S a l ly was ty pical o f m a ny you ng ath l e tes needi n g

a nd s he w a s able to understand t h e mech anics of its

to come to the rea l i s a t i o n t h a t top-level com petition

prod uction and perpetuation . Consequen tly. she was

tends to come w i t h a price: the pain assoc i a ted wi th

ab le to cope with her problem and contin u e to train

tra i n i n g a n d competition . She conti nued to su ffer

and compete at the top level.

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1 7 . 2 2 5-2 3 9 .


M e d i al c o l l ate ral l i gam e n t


re pai r i n a p rofessi o n al i c e h o c key p l aye r David M agee

� Tom i s



professional hockey player who was inj ur ed

during the first

period of a game. At the time , he was

body checked by


opposin g player and at the same

swelling and to give the inj ury a chance to ' settle down ' . A prinlary concern a t this time was the i nsta b ili ty of the knee, as well as the possibility

that the inj ury mi ght

moment his foot caught in a rut in the ice while he was

be season ending . During the surgeon's assessmen t ,

weight bearing on the limb. With the bo d y check, a val­

both t h e team trainer and team physical therapist were

gus stress was applied to the leg and the atWete fell to the ice. During the contact, Tom experienced

pain and

present and the fm dings s tated were

based on the

examin ation of the surgeon . It was felt that fo r the team

when he got up and tried to skate he noted that the lmee

trainer or physical therapist to repeat the tests wo uld be

did not feel right, and so he skated off the ice, The trainer

cou nterprod uc tive because of Tom ' s apprehensio n , the

questioned Tom on the bench and then took him to the

starting presence of muscle spasm, which may have

dressing room where the team doctor,


affected the acc uracy o f some tes ts, and the desire to

surgeon, saw him, This game was the fo ur th game of

ensure the vascu lar clotting mechanism wou l d be


this seaso n , Tom had missed a l l of the pre-season

interfered with mini mally. Because the mechanism of

training camp and the beginning of the season because

inj ury was seen by the medica l personnel at the time of inj ury and because the inj ury was repl ayed several

of prol onged contract negotiations, So, in addition to the mechanism of inj ury, conditioning and timing may

times on video playback, it was fel t there was no need to

have been factors that contributed to the injury.

clear other j o ints or to do neurological testing. It was

On in itial assessment,

d etermine d

the orthopaedic surgeon

t h a t there was a va lgus laxity in the knee,


consensus opinion that the MCL had su ffered a third degree sprain and the ACL h a d p r o b a bly s uffered



one would normally

degree sprain. As muscle spasm had begun to set in a

expect to find with an intact liga ment. There appeared

defmi tive diagnosis was impossible and so trea tment to

to be some positive anterior drawer motion ind icating

minimize swelling and pain was immedi ately insti tuted .

withou t the ' abrupt stop' end-feel

inj u ry to both the medial coU ateral ligament (MCL) and the a nterior cruci ate ligament ( ACL) .


At the time of the i ncident, Tom was very appre­

other tests

hensive about the extent of the inj ury and what e ffect

were nega tive, al though muscle spasm was be g inning

it would have in t he short term, in addition to his l o n g­

to manifest itself. with the range of motion being

term prospects as a hockey playe r. A l th o u g h he had

limited . S trength was slig h tly less on the inj ured side as


a result of re!1ex inhibition ca used by pain. Tom

a t being i nj u red so soon after returning to the team to

u n d ersta n

d ing o f the i n j u ry, he was a lso a g i tated

was immedia te ly given anti-in tlamma tory medication

p l ay. He partly fe lt he was ' l etti ng the tea m down ' .

( d iclofenac: Voltarin Rapide) and s tarted o n a pro­

I t also b othered h i m t h a t he should be i n j ured when

gramme of ice, compress ion , and elevation to prevent

he was i n ' the best s hape h e had ever bee n ' after

1 80

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mm) a n d a g r ad e I me d ial opening

s pend ing a great d e a l o f time working o n his fi tness

translation o f 1 0-1 6

o ve r the sum mer. Because of the apprehension on

(a valgus gappin g on the medial side of 5 mm on testing

Tom 's part. the medical tea m decided t h at treatment

in exte n sion ) ( K e nne d y. 1 9 7 9 ; Muller. 1 9 8 3 ) . He also

wo u ld be very conservative.

h ad a lmee that hy p er ex t en de d As Tom d id not com­ .

A fter the a p plic a ti o n o f ice. co mpress ion and e l eva ­ tion. To m was p l a ce d in an immobilization brace with

crutches to protect the knee and wa s given an a lges ic s for pain c o n t r o l

fn this case. the knee immobilizer


p lain of any p r ob le m s. no special programme for

knee was instituted in the intervening ye ar s



At s urgery. t he p a te ll ofem or al artic u l ation was fou n d to be normal and the medial and l a teral femoral

brace consisted of an open foa m sleeve. which was

gutters were devoid of loose bodies. The s upra p ate lla r

clo sed with six velcro straps ( th ree above knee. th ree

pouch was normal and only mi l d l y hy pe r a e mic The

below knee) and medial and l a tera l articulated bar su p p o rts . The b race was removed fo r re h ab i l i ta tio n . The next day Tom was seen by the athletic tra iner.

were normal. as were the medial fe m o r a l c o n d y le and med ial

who conti nued the ice. compression and eleva tion treat­

looked normal throughout its l e ngth ; a lth o u gh i t

ment. and in add i t i o n . insti tuted qu adriceps setting

appeared fIrmly attached arou nd the periphery. there was a small amount of fray in g at its posterior attach­

( i s o m e t r i c q ua dr ice ps in extension) a n d co-contraction


l a teral femoral condyle and l a te r a l t ib i a l c on dy l e

tib ial con dy l e . On first v i e w i n g the medial menisc u s .

o f qu a dri ce p s and hamstring exerc ises to main tain

men t . T here was no teari ng wi thin the intersubs tance

musc l e activity. Tom was able to do the exercises

of the medial meniscus . but there was some disr u pt i on

with no ap pa re n t d i flku lty. This same treatment was

of the m e nisc o tib ia l fIbres in its u ndersurface, giving

continued for

2 d ay s . Two d ay s after Tom was inj ur e d


a small

am o u nt

of increased mo bility to the meniscus

he u nderwent a magnetic resonance imaging scan.

when probed . The surgeon d e c i de d that this small loose

which ind icated that th e ACL was intact and that th e

part of the meniscus could be c augh t or an ch ore d in

MCL h a d suffered a third d e g re e strai n or rupture . thus

the su t ur e used to repa ir the MCL. The in t e rcondy l ar



con rlr mi ng the clinical diagnos i s . Over the n ext two

notch showed a cruciate l ig a m e n t with all fib r e s intact,

d ay s u n t i l su r ger y Tom received ice. compression . ele­

but the fibres themselves demonstrated a s m all amount

vation . and range o f motion exercises to the knee to

of looseness when probed , as if t her e had been a preVi­


control the swelling and to kee p the pain at a mini­

ous se co n d d eg ree tear of the i n tersubstance tissue.

mu m . T h e knee was taken out of the brace while the

There was a small amount of fresh bleeding ar ound

athlete performed the exerc ises. C r u t ches with partial

the femora l attachmen t of t h e fIbres o f the ACL . Th e

we ig h t be a r ing were s t il l u sed by To m


surgeon fel t that the new inj ury to t he ACL was prob­


ably i n s i g nift c a n t and i t was deemed un necessary to tig h te n the structure. Having i ns p e c te d the knee

Su rge ry

j oi n t , the s ur g e o n r e m o ve d t h e ar th r os c o p e and made

Five days after the injury occur red. Tom undenvent

a small me d i a l i n cision . On v ie w i n g the MCL , the s u r­

arthroscopic s urge ry to the right knee to repair the MCL

geon noted a complete tear, which was t he n r epa ir e d

and to re a tt ac h the m en i s c o tibi a l fibres. The prev ious

t hro u g h the sa me incis i o n . Final ly, the incis ion was

history indicated that Tom had inj ured the sam e knee

s u tur ed a n d

while pl ayin g in col lege. ft was recorded in his preseason

geon ' s postopera tive plan was for a very con tro l led

team 6 years ear­

r e h a b i l it a ti on pro g ra mme avoid i n g valgus s tress to

assessment by the pro fe ss io n al h ockey

lier th at he had a gr a d e II Lachman's test ( an an te r i or

the kn e e


pressure d r e ss i n g app l i ed . The sur­


R E ASO N I N G D I S C U S S I O N A N D C L I N I C A L REASO N I N G C O M M E N TA RY What was your i n te rpretation of the fi n dings at su rgery an d the subsequent surgical repai r

Based on clinical fIn d i n g s . the m ag n e ti c re son an c e

with respect to you r plans fo r manage m e n t, precautions req uired and the patien t's prognosis for recovery!

• Cl i n ic i an 's an swe r a n d su r gica l fI n d i ngs a decision was made to begin .

s tre ng t h e n i n g and range of motion exercises using

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pain as a guideline as soon as the athlete wa s able.

The surgeo n ' s p h i l o so phy was that there was no need to restrict exercises to certain ranges of motion as l o n g as the exercises were done care ful l y and with



a l th o ugh no attem p t was made to i ni ti ate

a ny v a l g u s stress motion at this stage. The su rge o n s '

th i n k i n g was tha t. i t" he had done a p ro p er repair. con­ trolled ran ge of mo tion exercises within the p a i n - free ra n ge would not h ave an adverse effect on the re pa ir


In addition . cryo th era py was and pa i n . The prognosis for

used to control swel l i n g recovery was exce l l e n t

b e c a u s e the su rgery was successful a n d t here were no com p l i catio n s . the p a t i en t was very fit and moti­ vated . a nd the rehab i l i tation program me was i n iti­ ated belore s u rgery and conti n ued w i th o n ly on e d ay off for su rge ry.

• Cli n i cal

reaso n i n g commentary

The clinician's reference to the surgeon's ph ilosophy and th ink i n g

rega rdin g

postoperative managemen t.

h i ghlig ht s the col laborative decision making essen tial

approach. Although n ot such . prognoses. like diagnoses. represen t clinical pat terns. Qms ide ra t io n of pro gn o sis . along with positive and negative features of the in


multidiscipl i n ary team

always thought of



presentation that may influence the prognosis ( relat­

ing to both the perso n and t he problem ) will assist cli­ to i mprove their prognostic decision ma king import a ntly. when a progn ostic hypothesis does nOI eve ntuate. the clin ician should then take time to renect on why, includ ing considerat ion of aspects of the patient's presenta t ion that perhaps were under­ or overweighted at the i n i tia l assessment. .

n ic i a ns


p ostsu r gica l assessme n t of the knee was requ ired . History i nd ica ted the knee was pain fu l fol l ow i n g the

• Stage

s urge ry Observation s h owed the knee to be held in .


approximate ly 1 5 degrees of l1exion. with a 1 5 cm wide

Because of the nature of the inj ury elld the antici p ated

e l astic/ace/tensor ba nd age appl ied. O n re mov i n g the

long re h abil i tat i o n programme . it was te a m practice

elastic band age. the wound area was clean and s h owed

t h a t the tea m physical ther ap ist become the dominan t

no ind ication of i nfec tion .

caregiver. providing regular reports (at least two or three

cool . a l though sl i g h tly warmer t h a n the u n i n j ured



p al p atio n the knee was .

who is the coordin­

kn ee , es p ec ia l l y a dj ace n t to the s urgic al scar. Active

ator of medical services. and t h e team p hysi c i an, an

moveme n t tes t i n g demonstrated th at the ra nge was



week) to the team

orthopaedic surgeon who performed the surgery.

restricted to 1 0-4 5 deg rees by pain an d a soft tissue

When Tom was seen by the s p or ts p hysic a l thera­

c a ps ular end - fee l . with obvious musc le weakness.

pist fol l owi n g surge ry, a regime n o f ice. compression,

notably of the vastus medi al i s This was confirmed

elev a t i o n a n d quad riceps setti n g a nd co-con traction

resisted isometric tes ting . with a graded strength of 3 / 5

isometric exe rcises was i nstituted immediate ly. O n the

for the q u adrice p s in the range of motion available. The




second d ay, a range of motion exercises were added

h a mstr ings

w i t h i n the pain-free range to try to res tore range of

ran ge of motion available. Passive movement indicated

motion. A n a lg e sic medication was used as we l l to

a soft capsular end-reel in to both flexion and exte nsion .

demonstrated a stre ng th or 4 + /5 in the

h ad

his surgery t he

con trol pain . A l tho ug h this p a i n was real to Tom . it

As Tom

must be remem bered tha t his p a i n to lerance was

li gamen tous testing was perJormed. Sensory tes ting

j udged to be low. Depend i n g on the s t a t e of the knee,

was negative except for a 5

a n ti - i n t1ammatory medica tion s were used fro m time

surgica l scar. which was numb. Interstitial swe l ling in

to time by the s p orts p hy s i cal the ra p is t in cons u lta­

the knee was evident , but swe l li ng i.n th e j oint was min­

tion wi t h the or th op aed ic su rgeo n . If there was evi­

imal. Mobility of the patella was lound to be s l ightly

j ust had


p revious day no .

area distal to the m e di al

dence of overuse in th e knee (swe l l i n g or pai n ) . the

restricted med i ally and la terally because of interstiti a l

a n t i -i n l1ammatory d r ugs were used to co ntrol symp­

swelling bu t p ate ll ar tracki ng appeared norma l . .

toms and treatment was mod ified. When first see n by the sports physi c al thera p i s t


Tom presented with the knee held in sli g h t flexion

• Stage


i n a n 'off- the-shelf ' knee brace. A lth ou g h the thera­

Early i n the tre a t ment programme. Tom showed

pist had been i nvolved i n the i n i tial assess me nt . a

that he was a nxious to

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i m p rove

a nd d emons trated


a certain a m o u n t o f fru s tration at t h e slow matio n , not the t h erapis t ' s ) rate


( i n h i s esti ­

improvement. The c on ti n

u a lly

in retur ni n g to the team because he was

c a u sed b y s a l ary

n ego ti a tion s with



h old o u t '

the tea m and had


n o t attended the tra in ing camp at a ll . In fact. he d id

to adv ise him that he was prog ressi n g a t a rate tha t

n o t retu r n to the tea m until wel l a fter the fi rst month

wo u ld be considered q u icker t h a n nor m a l . but th a t

o f league pl ay He fel t he was i n the bes t sh ap e

tissue recovery wou l d ta ke time progressing fr om t h e

ever been in prior to the start of the seaso n ; to h ave

i nfl amm atory p ha s e t o t h e fib ropl a s i a p h a s e , a n d

t h i s i nj u ry occ u r d uri n g o n ly his fo u r th game after

therapist treating Tom fo und th at h e

he h a d


fi n a l ly t o t h e maturation p h a s e . W h i l e Tom seemed to

retu r n i n g presen ted a q u i te sign ificant psychologica l

understand what t h e thera pi st was say i n g , it d id not

b lock for the pl ayer. The other fa ctor was Tom ' s rela

make i t a ny easier for him to accept that he had been

t i vely low pa i n tolera nce, which led h i m to bel ieve he

inj u red .


Part of th e


for t h i s is t h a t he w a s l a te


n o t i mprov i n g q u i c k ly e n o u g h .



main­ th is wa s prob ab ly a way at his (in his v i ew ) s low

You have desc r i bed a psychological bloc k.

G iven the inj ury, Tom conti nued t o work o u t t o

H ow did this manifest? What were the key

ta i n h is gen eral l1tness Part of .

featu res that emerged in either the subjective

of c h a n nel l i ng his fr ustra tion

examination or in later di scussions through

progress, but this activity was to later lead to problems

the treatment that enabl ed you to recogn ize

of general fati gue and co nce r n about the effect of fa tigue on the heal ing process of his i nj u ry. Bec a u se he

th is pattern?

was one of the top athletes on t h e te am , his inability to

• Clinician 's an swe r

contribute to the team pro b a bly a l so led to fr ustra tion

The psychologica l block was indicated by Tom ' s a nxi ­ ety at n o t getti n g better or not i mproving as fa st as he thou ght he shoul d . This frustration was conti n ually demo nstra ted by Tom in his qu estioning of his progress and his i nj u ry such as why he was not gettin g better .

fa ster and why the pain was not gO ing aw ay and the .

depressi on he demonstrated when things d id not go the way he wan ted. Tom wou ld demonstrate this depres­ sion by

his demeanour (slouching, swearing to h imself. grab b i n g a n d squeezing things) .

addi­ bec au s e he

and the feelin g he was letti ng the team dow n. In tio n , To m m ay have h ad


fee ling of guilt

was late j o ining t h e team as a res ul t of the con tract h o l d out. Tom' s low p ain tolerance was also a com­ plica t in g facto r. Thro ughou t the

tr eatme n t


To m was

conti n u a lly assured that he was progressing very we ll and that a ny se tbac k s h e experienced were part o f the healing process and . i n part. a res ul t of the agg ressive tre atment. The

clinicia n had to

m o n i tor p rogress very

care fu lly and watch that Tom was not being pus hed ' too h ard ' . Later i n the treatment programme (when h e bega n skatin g ) , Tom w a s g iven a n opportu n i ty to acco mpany the team o n one of t he road t r i ps w hi c h .

The indi cations of a psychological block

helped his psyche a great deal. The psychologica l over­

we re identified at only 3 days after su rgery. At this stage, what were your thoughts on the significance of the psychological aspect of his presentation for yo ur man ageme nt?

l ay may also have affected h is pain to lerance. However, even before a n d s ince the injury. Tom showed simi l a r low pain tolera nce w i th other i n j uries. While o n e might

think i t wo u l d be wor t hw h ile t o sen d him fis h­ some s i mil a r relaxing activi ty, s u ch an action '

ing' or

• Clinician 's answer

wou ld be even h arder o n the ath lete because he wou ld

While i t is common for a n i nd ivid ual to be conce rned

feel he was not doing eve rythi ng he should to get

abo u t his/ her inj ury, To m spen t an inord i n a te a mount

bet ter. During the seaso n , these athletes o n ly get

d i sc us si ng his inj u ry. its progress and h is res ulting frustration at not being back with t he te a m .

abo u t 1 d ay per month in which they are not involved

of time

in hockey-rel ated activities .

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: .


• C l i n ical

reaso n i ng c o m mentary

be at tended to. and even screened for. with the v iew of

The key issue here. as discussed i n Chapter 1 . is that

identifying where the patient's psychosocial status

patients ' psychological status . includ ing their u nder­

may be interferin g with or cou nterprod uct ive to their

s ta n d in g of their proble m s and man a geme nt and

recovery. By givi ng this dimension of

how they a re coping with the effects their problems

entation the same consideration that is normally pa i d

are having on their lives. can have significant i n flu­



greater ski l l s in assess ing for and recognizing p attern s


their pain perceptio n . the responsibil ity they


impa irment.



patien t's pres­ can

de velop

take in the ma n a gement process and ultimately their

of psychosoci al presen tations that

o u tcomes Like physical clinical syndromes patients '

sus counterprod uctive. As is the

psychosocia l status will present in patterns . However.

pa tient. management can t he n be varied accord i n gly

\-" ith patterns of physica l impa irement. care is

and prognosis viewed with appropriate consideration




needed not to ove rly ' box' a patient's psyc h ological





wi th this

to these is s u es .

status . Rather. cues of psych o so c i a l problems should

In a n attempt to a l leviate Tom ' s fru s tratio n . he was

wa l king outside while wearing the brace ( it was wi n ter

put on a fi tness progra mme for his u pper body and

in Can ad a ) . Whi le the in creased pain c a u sed Tom

u ninj u red leg 3 days after su rgery. This action was

some conce r n . the res u lti n g ir ritation settled dow n

taken to get Tom ' s mind off his inj ury and to m aintain

within 1 d ay and he was able to continue w i th his nor­

h i s cardiovascu lar fitness. The fitn ess prog ramme was

mal tre atment a n d fitness regimen s. Ten days a fter the

d eve loped by the team fi tness consulta nt with i np ut

operation. the surgeo n removed the su tures . Tom still

from the team phys i ca l therapist. Seven d ays post­

demonstrated a l ack of 10 de gree ex ten s i on be ca u se of

s urgery. Tom bega n to use the bi cyc le ergometer with

ca ps ul ar sti ffness. In the ea rly stages of trea tmen t it is

n o res i sta nce in an attempt to restore more of the flex­

common practice with this med ica l team to work

ion range o f motion . I n i tia lly. Tom was given electrica l

within the ra nge available b ut n o t to p u s h th roug h


muscle stimu l a tion to the q u a dr i ceps because he was

p a i n i n to fu l l ex ten si on

having trou b le ' t u r n i n g on' the q u adriceps to extend

ava i l ab le n atura l ly Tom wou ld have been worked i n to


If fu ll extension had be e n


the knee. Once a good co n trac ti on of the qu adriceps

th at range.

was a c h i e ved (two treatments ) . the e l ectrica l s timul a

degrees. Qu a driceps s tren gth had i ncreased to 4 / 5


Flexion h a d i mp roved to about

1 20

tion was di scon ti nued An i nteres ti n g findi n g w i t h thi s

within the ex is ti n g ra nge whi le ha ms tri ng strength

patient w a s tha t he demonstrated only mi n ima l

wit h i n the availab le range was no rm a l . Passive move­



swe l l i ng (swel ling only s lig htly evident with the swipe

ment testing at this stage i n dicated a capsu lar end - feel.

test) a fter the su rgery and th rou ghout the fu l l rehabil­

However. because the ti ssue was in the early fi bro­

i ta tion prog ramme. The main g u i d e u se d by t he phys­

p l a si a phase of heal i n g . it was ['e lt that i n creases i n

ical therapis t in d etermi ning how far Tom could

ran ge of motion wo u l d be attempted pr i mari ly by

exercise was the pain level . Because To m ' s pain toler­

ac tive range of motion exercise s . w i th some gent le

a nce was low. however he was en coura ged to d o con­

passive ra nge of motion elastic stretch i n g to provi d e

trolled activ ities even if they were u ncomfor table.

o n ly a sma l l amou n t of h ea lin g stress to t h e ti ss u es .


P rovid ed


pain or d iscomfor t ended re latively

qu ickly a fter stopp i n g the activi ty. it was felt the inj u ry was n o t bei n g overstressed . Swe l l i n g pl ayed a very

• Stage


i n s i g n ificant role. a nd even when pushed, the restrict­

In order to retra in the proprioceptive feed back system

ing factor was pai n not s we l l i n g D u r i n g this time and

affected by the s u rgery. propr ioce p tive and control

s u b s e q u e n t weeks. Tom wore a n off-the-shelf fi b re­

exerc ises were begun. Exercises incl u d ed wei ght shil't­


glass knee brace presc ri bed by the s u rgeon to protect

ing. bal ance exercises (one legged ) i n combin ation

his knee med i ally and latera l ly. while al l owi n g flexio n

with body bl ad e (Fig. 1 2 . 1 ) . ba la nce board exercises

and extension w i t h i n the ava i l able range of mo tio n


(Fig. 1 2 . 2 ) . use of a b a l a nce m a c h i n e . as well as more

Nine days a fter t he i n j u ry. Tom experienced a sud­

vigorous cl osed k i n e tic c h a i n q u ad ri c eps a nd ham­

d e n extension force on his knee when he slipped on ice

stri n g exercises ( F igs 1 2 . 3 a n d 1 2 . 4 ) . i ncluding si n g l e

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F i g. 1 2 . 3

Ath l ete on i n c l i n e p l a n e u s i ng body weight as

res i s ta n c e . N ote the u n sta b l e base.

Fig. 1 2 . 1

Exa m p l e of oscillating body blade used for

prop rioceptive tra i n i ng.

Fig. 1 2 . 4

Ath l ete d o i ng s i ngle l eg pres s . N ote knee

flex i o n d o e s not go past 90 degre e s .

correctly i n the available range were all owed . These exercises provided a s m all heal i n g stress to the i n j u red tissues. as we l l as range of motion and strengthen i n g effects. The progression of exercises was b a s e d o n t h e ability o f Tom t o con trol t h e exercise h e was asked t o do a n d on t h e pain response. Very speci fic instructions were given to Tom and i f h e devia ted he "vas stopped to prevent incorrect movement patterning from devel op­ ing. When Tom demonstrated an ability to do an activ­ ity the repeti t i o n . weight used or time were increased. .

A t the same time. Tom's work on the bicycle ergometer Fig. 1 2.2

Ath l ete on ' Profltter

(dynamic balance apparatus,

re p rod uced w i th p e r m i s s i o n of Fitter I n te rnatio n a l I n c ) .

increased from 5 minutes with no resista n ce to 2 0 m i n u tes wit h resistance n o w being i m p leme nted . The seat height was modified as h e went through the exer­

leg wa l l s l i d es and tu b ing i n to extension w h i l e weig h t

cise regimen. w i th the height lowered every 5 minu tes

bearing. W h e n d o i ng t h e exercises, t h e therapist

u ntil knee l1exion became uncomfo r table.

watched to ensure t h a t correct. controlled motion

One of the problems th at had to be dealt with e arly

occurred. Ofte n. beca u se of inj ury. proprioceptive feed­

i n the reh abilitation process was the n o ticeable q uadri­

back and the abi l i ty to c o n t� o l motion is lost to some degree. Consequen tly. on ly moti o n s t h a t Tom could do

ceps lag that developed before fu U exte n sion was achieved. Diligent work by Tom , however. led to full

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as well as ascending/descendin g stairs at speeds (slow) at which he felt comfortable and the therapist felt he cou ld control. In add i tion , on the balance m achine, target train ing was instituted with the targets designed to increase the valgus stTess to the MCL (Fig. 1 2 . 5 ) . By concentrating on keepi ng the ' dot' on target. Tom was working on main taining control whi le



MCL an d facilitating the mechanoreceptors in the jOin t and muscles .

• Stage


Ab out 3 weeks followi ng the surgery, w a s i nstitu ted t o faci litate fu r ther t h e

ultraso und healing a n d

fibroplaSia phase of the tissue. It was felt by the physi­ c a l therapist that. given the normal continuu m of soft tissue healing (clotting phase, in flamma tory ph ase, fibropl asia phase and maturation phase ). Tom was now wel l into the fibroplasia phase of heali ng and at t h is stage ultrasound would be effective in he l ping stimulat­ ing co l lagen form a t ion . The end-feel a t


point was

still tissue stretch. bu t the pa in Tom was feel i n g on Fig. 1 2 . 5

Ath l ete on balance mac h i n e . Base may be

static or dynamic. Ath lete is concentrating on keep ing h i s cen tre of gravity by viewi ng the computer s c r e e n a n d either statica l l y or d y n a m i c a l l y main ta i n i ng the ' ba l l '

passive stretch was decreasing. It was als o found dur­

ing application of t he ultrasound to the medial side o r the


which was the area o f origi n a l n u mbness.

that this are a had become extremely hypersensitive to

active ex tension wi thi n about 10 days of accomplish­

to re p­ rather t han just a low pain tolerance. By con tinued use of the ultra­

ing full passive extension range of motion . This lag was

sound over the area and by giving in structions to Tom

the movement of the sound head. This appeared

i mage cen tred .

resent a true decrease in pain threshold

of i n i tial concern because, as long

as it

was present, i t

indicated t h a t he did not have control i n part o f his

to rub the area gently w i th


skin cream to help to

desensitize the tissues, the hypersensitivi ty decreased

extension range. making him potentiaUy vu lnerable to

over a period of time although the numb area re maine d .

injury or re-inj ury. The exercises included quadriceps

Tom continued to work out to matnta i n h is physic a l fit­

setting exercises. wall sl ides . 90 degree squats and

ness. In fact, it was fel t by the physical thera pist that he


extension against tubing resi stance. With full exten­

was working out too hard,

sion and the ability to do closed kinetic chain activities

working on his physical fi tness. Because he was becom­ ing exhausted from worki ng so hard to

and leg straightening exercises. Tom

began j ogging very sl owly forwards and backwards .



the other parts or his body main tain a nd improve his fitness level . it was

with no difficulty and no adverse effect. more vigorous open ki netic chain activities were insti tuted beyond the

quadriceps setting

6-8 hours

hypothesized that this may have been impeding the healing process.



What is the pathophysiological basis for gen eral fatigue to interfere with the heal i n g p rocess !

• C l i n i c i an 's an swe r


Gene ral fati gue can be t he resu l t of severa l factors. Fatigue may be cen tral or periphera l . both of which

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may direc tly o r ind irectly a ffect t h e hea l ing process. Metabol i c fatigue is prima rily periphera l .

lea di ng

to reduced ATP. l o wer bl ood gl ucose leve l s . musc le glycogen depleti o n . de hydra t i o n . and loss o f elec­ tro lytes. Neu romu scular fa tigue. w h i c h may occur peri phera l ly or c e n tr a l ly. c a n resu l t i n substances competi n g for receptor s i tes . in creases a nd


cholin esterase

acety l c h o l i n e decreases


• C l i n i cal

reaso n i ng co m m entary

The biomedical k n ow l edge evident in this a n swer. along wit h the c l i n ical i mplication n oted i n the cl i n ­ ician 's last sta temen t, highlights the comb i n ation of

biomedical and c l i n ical kn o wl ed g e th at con tribu te to ex pe rt therapists ' orga n ization of professional


kn o w l edge The cl i n i c i a n ' s hypothesized i nvol ve­

impai red neuro m u scu l a r tra nsmission a n d /or propa­

ment of the en docri ne system il l u s tra tes a broad per­

gation of a muscle action poten t i a l . a s well a s redu c e d

s pec tive beyond the obvious l oc a l

m o t o r un it recru i tm e n t and a p sychological ove r l ay.

repa i r and supports the value of i n c l u d i n g pathobi­


tissue i nj ur y /

es pec i a l ly i f the fa tigue is c h ro n i c . Electrop hysiologi­

ological hypotheses in one's clinical reason ing.

c a l fa tigue l e ads to decreased membrane po te n ti a ls .

Such considerations should encourage therapists to

A l l of the types of fa t i g ue a ffec t the fo rce-generating

be alert to the l i nks between the va ri o us i nput. pro­

c a p a c i ty of t he muscle as we l l as affecting the ' b uild­

cessing and output mechanisms that are known to

i n g blocks' of re pair through s tress o n the endocri ne

exist. For example. similar to

syste m . w h i c h wi l l . i n tu r n slow the reh abilitation

patien t's observed fru s tration may also have been


progress i o n .

t he


c o n t rib u t i n g to st r ess-re l ate d end ocrine effects such

as a l t e red sleepin g and compromised healing.




c l in ica l reasoning requires a h jghly developed a n d Do y o u fe e l th i s pati e n t'S psyc h e , w h i c h y o u h ave

contextu al ly releva nt o rga n i z ati o n of knowled ge.

al ready h igh l ighted as a p ro b l e m , cou l d

Contemporary manual th erapy requires that th is

a l so be contri b u t i n g t o h i s fa tigue a n d hea l i ng

know l ed ge base includes u nderstanding of the inter­

c a p a c i ty?

re l ati o n s h i ps between the different body systems ( e g psychological st atus, sensory-motor, endocri n e .


a n d immune system s ) .

• C l i n i c i a n 's answer




di fferent systems, management. i n cl u d i ng

symptoms of impairment i n the

Tom's psyche may h ave c o m p o u n ded the fatigue


and how best to modily

overtra i n ing p r o bl em s . O fte n , espec i a l ly in the e a rly

appropriate referral when i m pai rme n t i s suspected .

stages, To m r e p o r ted d i ffi c u l ty with sleep i n g and

While it is not poss ib le lor the manual th erapist al so

t ired ness, not bec a u se o [ t h e inj u ry. b u t bec a u se o f

to be a psychologist. endocrinologist a nd i mmunolo­

having ' n o t h i n g to d o ' during t h e d ay a n d even i n g


a lt h o u g h he spen t an i no rdi n a te amount o f time

' working out' .

gist. we are o ften the firs t person w i th wh ich the

patient shares s uch symptoms. a n d as s uch it is criti­ cal that manual therapists at least have the knowl­ edge and awareness

• Stage

to seek further consultati o n .

To m ' s reaction to t h e new l o a d . Tom was c o n ti n u a lly


monitored during the exercise, with the therapist noting

By 3 weeks , Tom was d o i n g one- legged wal l sl ides as

any change in symptoms wh ile ridi n g the bil(e, after

wel l as balanC i n g exercises, l u nge exercises . a n d sev­

treatment. and before beginning treatment the next day.

eral d i fferent quadriceps exercises. Ball b o u ncing exer­

Tom was made to u nderstand the difference between

c i ses were instituted to im p rove fur t her l1ex ion ra n ge

stress pain , which djsappeared when a ctivity stop ped ,

of moti o n , pro prioception and b a l li s t i c a l ly con trolled

and pain that l in gered after the activity stopped , ind icat-·

much stress was applied to the knee. By 4 weeks,

mot i o n . A s we l l . resista nce was continu aUy added to

ing too

the bicycle ergometer exerc ise. The a m ou n t o f resist­

Tom had progressed on the bicycle ergometer to approx­

a n ce set o n the b i cycle ergometer was determined

imate ly 1 0 0 watts resistance and the seat had been low­

by the desired stress to be pl aced on the knee, and not

ered close to



card iovascul a r tra i n in g

normal funclional levels.

e ffec t . The

As wel l as doing exerc ises with the therapist o ffer­

desired level o f stress was d e termi ned subjectively by

i n g resistance or u s i n g t u b i n g , the use o f exercise


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: :


mach ines was also instituted (leg press, h a mstrings

skating type motions. Resistance was i n i ti a l l y applied

m a c h ine, abductio n / adduction machine with resist­

above the knee, but as the hea l i ng process progressed

a nce above knee) . Repe titions a nd weight were set

the resis tance was appl ied to the tibia to i ncrease the

d ependin g o n Tom's abi lity to do the req u ired repe­

healing stress to the tissues that had been repa ired .

titions wi thout ad verse symptoms . Alternate days

With these functi o n a l activ ities , Tom's a b i l i ty to con trol

were used for stre ngth ( h i g h load . low repetitions) and

th e m ovemen t was the decid i n g factor concerning

e ndura nce

repetitions and l oad . As soon as Tom d emon strated loss





tra i n i n g .

Tu b in g was a l so progressively u s e d w i t h more a n d

of con trol (a ltered movement p a tterns, a ltered muscle



contraction pa tterns any where in the kinetic c h a in but

pro prioceptive neuromuscular facil itation (PNF) pat­

espec i a l ly at the knee or more prox im a lly in the lum­

ter n s a nd o b l ique movement, as we U as resistance in

bopel v i c-hip stabi l izers ) , t h e exerc ise was stopped .

� J -

fu nction a l

activ ities .


a s resis tance


With p a i n asse s s m e n t for m i n g a s ign ificant

(relative to what wo u ld norm a l ly be expected ) , care

component to the p rogressi o n of re h a b i l i tation

had to be taken when conSid ering the nu mber o f rep­

for t h i s patient, can you com m e n t on the

e titions and progress i o n in the re habilita tion pro­

d i ffi c u l ties that can a r i se when the athl ete does

g ramme so tha t the ' progression e nve lope' was not

not accurate ly report the onset or seve rity of

p us hed too far. Continual closely supervised m o n i tor­

pa i n ! Were there any pati e n t- i n d u c e d

ing enabled the cl i n ician to keep w i t h i n an acceptable

re habi l i tation problems w i t h t h i s pati e n t, s u c h

envelope of progression .

a s i n a c c u rate pa i n reporti ng or ta k i ng of analges ics, that res u l te d i n h i s p rogram m e b e i n g advanced too q U i c k l y !

• C l i n i cal The

reaso n i n g c o m m e n tary

c li n ici a n ' s

recognition th at pain i s


di ffere n t

and unique experience for each patien t a n d should

• C l i n i c i an 's answer

be a c c e pt e d as such is evident here. He does not

Because of Tom ' s l ow pain tolera nce, the pain ' scale'

' j udge' the patient or discou n t his pain experience

h a d to be adj usted downward . Also, a n u nderstand­

a s non - ge nu i n e Rather. the ' p rogression envelope'

ing o f the di fference be tween the pain of inj ury and

i s adj u sted for this p a r t ic u l a r patien t while taking

p a i n o f ac tivity h ad to be determ i ned and the differ­

care not to rei n force the u n he l p fu l belief that pain


ence had to be u nde rstood by Tom . In t h is case,

necessarily equals harm.

To m t r u ly fel t the pain b u t w i th h i s tolerance so low

pred i spose to chronic p a i n .

B#i'iUN*"bhbB9"Nii _ • Stage



yel low f1ag th a t can

limi t i n g factor t o r a n ge w a s n o w felt t o be t h e tight capsule rather than muscle we akness. The therapist fel t the tissue healing was suffiCien tly prog ressed that plastic stretching to in crease the r a n ge of motion was

Five weeks after the su rgery. it was decided by the

the best route to follow w i t ho u t d isru pting the healing

physical therapist that as much ra nge of motion as

tissue. In order to d o this. the knee was placed so the

could be accomplished by doing ac tive exercises had

foot rested on a padded bar with the knee itsel f not

been accomplis hed , and therefore plastic s tre tch i n g

supported. A 6 1 b ( 2 . 7 kg) weight was applied to the

( t herape utic creep) of the tiss ues was instituted. T h e

knee along wi th hydrocoUator p a c ks and a 1 5 m i n ute

end-feel was sti l l a t i s s u e stretch (capsula r) , b u t the

stretch was instituted (Fig.

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1 2 . 6 ) . To accomplis h


negative psychological overlay a n d d i fficu l ty sleepi n g . Tom ' s fru strati o n w i t h his progress. wh ich i n real ity was exce llent. was a l most pa lpable. It was eve n tua lly hypothesi zed


his c a rd iov ascular fi tness pro­

gramme was crea t i n g major fa t i g ue prob l e m s fo r Tom . This was later s hown to be t r u e as Tom m a d e even better prog ress w i t h his k n e e re h ab i l i t ation when h e c u t back h i s fi tness p rog ra m me. T here w a s a l s o a c e r t a i n psyc l1010gical overl ay o n h o w we l l t he athlete fe l t he was im prov i n g . how q uickly he would get back a n d w h a t e ffect the i n j u ry wo u l d have o n his perform ance. This p a r t i c u l a r a th lete was the top ath­ F i g . 1 2 .6

lete and o n e o f the l eaders on the hockey team: there­

Plastic stretc h i ng ( therapeutic creep ) of

fo re, c o n siderable pres s u re was being put o n h i m

poste r i o r knee structu res. Note hotpacks a ro u n d knee

( both by h i msel f and t h e tea m ) t o re t u r n t o p l ay a n d

a n d weight applied o n top.

also t o pe r fo r m a t a very high level when h e retu r ne d . A t this stage, t h e fitness programme ( co n tro l l ed by therapeutic creep o f col lagen tiss u e , a s low prog ressive stretch shou ld be i n stit u ted l astin g 1 5- 3 0 m i n utes for maximum effect (Ko ttke et a1. . 1 9 6 6 : S apega et at. , 1 9 8 1 ) . Stretc h i n g fo r less t h a n 5 m i n u tes is unlikely to have m u c h permanent effect on the collagen tissue. Fifteen min utes was ch osen because of Tom ' s discom­ fo rt le vel a fter 5 m i n u te s . Maximum load when doing p l astic stretch ing s h o u ld be 8- 1 0 Ib ( 3 . 6-4 . 5 kg) (Kottke et al . . 1 9 6 6 : Sapega et a l . . 1 9 8 1 ) . By heating the tissues. therapeutic creep is more easily a c h ieved . Tom was able to tolerate t hi s very wel l fo r the ftr s t 5

minu tes a n d then fe l t the stretc hing become more a n d more uncomfo r t able fo r the rem a i n i n g 1 0 m i n u tes. With i n five treatments, sign i fic a n t improvement in ran ge of motion was n o ted , "vi. t h fu l l extens ion range o f motion and a normal tissue stretch end-feel accom­ plished w i t h i n

2 week s . At the same time, l1ex ion

ra nge of motion h a d v irtu a.lly returned to normal t hrough the exercise programme wi thou t p l astic s tretc h i n g .

• Stage

t h e team fitness cons u l tant at a n o th e r locati o n ) was fu lly i n tegrated into the knee reh a b i l i tation pro­ gramme, w i t h the phys i c a l thera p i s t h a v i n g fi nal say a s to what Tom wou l d be allowed to d o in b o th the fi t­ ness a n d the rehab i l i tation programmes. To m had t b e seat at a n o r m a l l e v e l while u s i n g t h e bicycle ergome­ ter and was cycl i n g for 30 m i n utes . The i n te n S i ty ( l o a d ) p l aced on the bicycle ergometer was now deter­ mined by the desired cardiovascu l a r effect rather th a n the stress o n the knee. Tom began by worki n g at 7 0 % o f his m a x i m u m heart r a t e fo r th i s effect a nd worked u p t o 8 5 % . O t h e r exercises c o n tinued i nc l u d i n g quadriceps exercises, using the b a l a nce m a c h i ne, b a l a ncing exerc ises. a n d more fu nctio n a l exercises such a s s l o w j ogg i n g fo r­ ward and backward , c a r i o c a exercises ( ru n n i n g side­ ways with cross-over step s ) , pylon r unning ( s l ow) fo rwards a n d backwards ( r u n n i n g a r o u n d py lons so person turns r i g h t and l e ft ) . figure-8 r u n n i n g ( s lo w ) .

and ascend i n g / descend i n g sta i r s . D u r i n g t h i s period . To m was fi tted with a custom fu nctio n a l brace. which h e began we aring duri n g his exercise p rogra m m e in


order to become used to it, a s h e would b e wea r i n g

By 6 weeks. Tom bega n doi n g Cy bex isokinetic exer­

t h is b r a c e whe n he returned t o competi t i o n . As t h e

cises a t slow s peed settings of 3 0 . 6 0 . 90 and 1 2 0

l e g d i mensions a r e u s u a l ly a l tered fo llowin g i n j u ry, i t

degrees per second maxim u m


is common practice for t h e medical tea m to fi t t h e a t h­

depend i ng on fat i gue a nd symptoms ) . A t this time,

( t h ree sets o f

lete w i th a n 'off-the-shel f ' brace initially to p rotect the

Tom wou ld h ave some good days and some bad d ays

knee because i t i s less expe ns ive. Once the leg d i me n ­

depen d i ng on how hard he pushed both his exerc ise

sions a r e close to norma l (compared wi th the u n i n­

for his knee and his cardiovascul ar fitness. A ' b ad day'

j u red leg) , a custom brace is fitted for the athlete to

experience for Tom was the knee not fee l i n g as good as

retu r n to competitio n . Com mon ly this brace is then

the prev ious d ay. with some aching combi ned with a

wor n at l e a s t u n t i l the end o f the s ea son . The custo m

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brace was a br a c e d e s i g n e d by a l o c a l or thotist to pro­ v i d e medial and l a t e r a l protection to the knee.

• Stage

• Stage


By the e i g h t h we e k , sk a t i n g was more r i gorous and

Tom was us i ng the exerc ise m a chi n e s at h i g her l evels


and h i g h er wei g h ts . Tom's skill l ev e l o f s ka ti n g even

By th e seventh week, in a d d i tion to the above pro­ g r a mm e Tom b e ga n s k i p p i n g and d o i n g h i g h - s p ee d .

C y bex i so ki n e t i c ex e rc i s e s ( s p e e d s : 1 2 0 . 1 8 0 , 2 4 0

degrees per sec o nd ; 1 m i n u t e exerc ise, 1 m i nu t e rest. t h ree repetitions a t e ach s p e e d ) for endurance. Also,

b a sed o n To m's ability to control h i s knee motion b o t h in c l o s e d and o p e n kinetic chain activities, more di ffi­ c u l t kinetic chain activ i ties were i n stituted , s uch a s

on e-le gged h o p exercises forward s , backwards , t o t h e

( + ).

s i d e , a n d aro u nd a c r os s

At the end of 7 weeks,

in a dd i ti o n to the above programme that continued,

Tom h ad d e m o n s tr a t e d a d e q u a t e str e n g th

c o n t ro l



e n d u r a n ce a n d ag i l i ty i mprovements to b e gi n skati ng. His i n i tial skati n g e p i so d e was 15 mi n u te s of e a s y

skating w i t h no eqUipmen t exc ept skates, e l bow pads, helmet, g l o v e s and stick. As T o m improved, the time, ,

s pe e d a nd difficulty of the sk a t i ng exercises were increase d . Initia lly Tom did not have a p u c k to handle o r shoot , b u t a p u c k was i n clu d e d a s he progressed to

make t h e activity more complex . Because Tom w a s


h i g h ly s k i l led h ockey p l ay e r, it was n e c e ss ar y t h a t th e

p hysic a l ther a p i st be present fo r all the i n itial s k a t in g sessions as Tom had a very st r o n g t e n d e n cy to want to do too much at each session . C o nseq u e n t l y, his acti v i ty

had to be very carefully controlled . Skating d r i l l s at the

at t h i s stage was better t h a n many p r ofe SSi o n a l

h oc ke y players a n d he had to be controlled to ensure he d i d not overstress the knee. S k i p p i n g a n d hopping were c on ti n u e d a s was sta ir work . Because of t h e con­

trol . strength a n d e n d u ra nce demons trated by Tom d ur i n g skating and d u ring his e x erc is es p l y om e tr i c s ,

were i n s t i t u t e d to i m p r o ve fu r ther the reactive ab i l i ty of t h e lower limb n e u romusc u l a r sy s tem Acti v i ties .

i ncl uded j umpi ng o n a n d off a b e n c h a nd j u mping over a bench .

By t h e end of

8 wee k s , To m

wa s

skating up to 4 5

minutes a n d the bicycle p ro gr a m me varied from one

d ay to the next: one d ay bei n g an endurance ( a e r o bi c ) prog ramme a n d the next day be i n g a s p r i n t ( a n a e ro


b i c ) prog ramme. This enab led training or t h e two p r i m ary energy systems ( 8 0% a n a e r o b ic and 2 0 % aer o bi C) u sed i n i ce hockey, as wel l a s i mprov i n g the aero bic system t o fa c i l i t a te re c o ve ry fo l l o w i n g exer­ cise. T h r o u g h o u t the p r o g r a m m e To m received treat­ .

ment 6 d a y s p er wee k on a o n e to one basis w i th the p hy s ic a l th era p i s t This high leve l of t r e a t m e n t v i sits .

is com mo n for profess i o nal


where fu n d ing is

not a n i s s u e but where g e t t i ng a highly t r a in ed and

paid a t h l e t e b a c k

t o p l ay i ng his sport i s o f prime

i mp o r t a n ce.

e a r ly stage i ncl uded skati n g h ard between the blue l i n es ( s tra i g h t a h e a d ) and coasting around the e nd s

( c u rve s ) , figure- 8 s k a ti n g crossing the 'T' a t cen tre ice ,

• Stage


(ska tin g forwards , backwards and s i d ewa y s within

By the e n d o r 1 0 weeks, Tom was c lear e d to sk a te with

the cen tre ice circle) , as we ll as just s ka ti n g w i t h t h e

the team i n p r ac tic e This is cl a s s ed as a controlled

p u c k d o i ng v a r i o u s s katin g dril ls (Fig. 1 2 . 7 ) . In ad d i


sk a tin g with control led acti v i ty as the a t h l e t e go e s

tion, Tom co n ti nu e d w i t h h i s skippi ng ( fo rwar d a nd

thr o u g h s p e ci fi c passing a n d s k a t i n g drill s a l on g with

b a c k w a r d ) , rid in g the b ike fo r 3 0 minutes, cl i m bin g stairs, and

wo r kin g

on the exe r c i se m a ch in e s



the r e s t o f the tea m , b u t th er e is no bo dy contact. If the athlete is a l l owed to retu r n to practise with the team,

h e is ex p e c ted to do e ve ry t h i n g other tea m m e mb e r s do, except for b o d y c ont a ct I n i ti a lly, the athlete is not .

allowed to scrimmage ( p l ay a contTo l led ' ga m e ' with other p laye r s )

unti l t h e med ical

team is sure the ath­

lete h a s no p robl em with tea m drills. If he h as no prob­ l e m s with the dril ls, as w a s the case w ith Tom , he is

a llowed to scrimmage. If he has no p r ob le ms with

scrimmaging and tests (Cy bex tes ts, fu nctional tests , phy s i c a l exa minatio n ) show no p r obl e m s , the ath lete Fig. 12.7

Player d oing pylon skating as p art of his

functional retraining.

i s a ll owed to return to c o m pe titi o n if he feels he is

r ea dy By the twelfth week Tom re tu rned to play. .

Copyrighted Material





Can yo u c o m m e n t on why you th i n k t h e


fl e x i o n i m p roved w i th active exe rc i s e wh i l e

u s e d to l e s s e n s u c h pressu res on the th e rapist a n d the ath l ete ?

t h e exte n s i o n re q u ired pass i ve stretc h i ng?

• C l i n i ci a n 's

• C l i n i c ian's answe r W hy flex i o n req u ired no

p l ast ic s tretc h i n g w h i l e

extension d i d i s d i rtku l t t o a sc e r ta i n . I t m a y have been because the b a ms tri n gs demon strated greate r s treng th

fo l l ow i n g s u rge ry. bei n g

a bl e

prog ressively t o

' s tretc h ' o r stress t h e a n terior c a p s u le m o r e ma rked l y


strcssed t h e MeL as much ( i n flex i o n , t h e a n terior fl brcs o f the l igament a r e pri m a r i l y stressed ) , a l low i n g t he a t h l ete to wo rk Alte r n a tively. n ex i o n m a y n o t h ave

o n nexion to a g reater d e g ree with less d i s c o m ro r t .

an swer

It i s common practice with the team invol ve d t h a t the physica l thera p is t i s t h e primary c a re g i v e r a n d determines t h e course o r treatme n t . in conj u n c t i o n w ith t h e p hYSi c i a n a nd team a t h le t ic tra iner. in s i t u a ­

tions w h e n physi c a l t hera py i s req u ired a rter surge ry. I nitial ly. there was


b r e a k d ow n i n c o m m u n i catio n

w i t h the fi tn ess pers o n bec a u s e t h i s was t h e fi r s t ye a r s uc h


per s on w a s a v a i lable to the

tea m . T h e s u rge o n

w a s rea d ily ava i l able i r t h e physic a l therapist h a d a ny ques t i o n s . since the s urgeon . phys i ca l therapist


Iltness p e r s o n a t tended a l l h o me hockey games ( aver­


What gu i d e d yo u r d e c i s i o n t o adj ust the

age o f one to two per wee k) . T h i s a l lowed the s i tuat i o n

p ri n c i pa l aim of the b i cyc l e e rgo m eter exe r c i s e

t o b e cont i n u ally reviewed and discussed w i t h t h e

fro m o n e b a s e d on t h e local stress p l a c e d on

a thletic tra i ner. c o a c h a n d genera l manager ( i r neces­

t h e knee to o n e of card i ova s c u l a r fi tn ess ?

sary ) . To m was seen by a l l people i nvolved. A l t h o u g h

a s soon value to t b e t e a m .

there was pressure to return To m to p l ay i n g as p ossi b le beca use of the p l ayer s '

• C l i n i c i an 's an swe r

there was n ever so

Once the po i n t was reac hed when Tom ' s k n e e wa s able to

stand the stresses o r normal closed kinetic

much press u re that he was fo rced

to return too e a r ly. With this tea m . the h e a l t h o f the ath lete is of p r i m a ry importance.

chain activity, and because no symptoms resulted from these stresses , it was fe lt t hat he could do normal cardiovasc u l a r tra i n i ng using both legs . Up to t h i s poi n t . Tom was using an u p p e r b o d y ergometer for h i s card iovascu l a r fi tness.

What was you r c l i n i ca l reaso n i ng a n d s c i e n tific rati o n a l e fo r i m p l e m enting plyom etr i c exe rcises at the eighth week (stage 9) ?

There seems to be a n u m b e r of h e a l th

• C l i n i c i a n 's

p rofes s i o n a l s i nvo lved i n th i s ath l e te'S

an swe r

rehab i l i tati o n . Co u l d you c o m m e n t on what was

As plyo metrics is a h igh s tr e ss activity t h a t req u i res

req u i red of th e thera p i s t in h i s i n t e r p rofe s s i o n a l

good control. it was not i nstitu ted until Tom could

co m m u n i cati o n w i t h t h e oth e r h e a l th

d e mon strate satisfactory control in fu ncti o n a l activ­


p rofessionals, the coac h , m a n ager, tea m own e r,

i t i e s . The purpose o f the plyometric exerc i ses was to

etc . ? H ow does this i m pact on t h e d e c i s i o n s

e n h a nce the neuro muscu lar system by i m provi n g its

m a d e b y t h e t h e ra p i s t a n d h o w can r i s k of

reactive abi l i ty thro u g h combining speed of move­

confl i cting i nfo rmati o n be m i n i m i zed when so

ment ( doin g the bounce in the j u mp q u ickly ) and

m a ny peo p l e are i nvo lve d ? T h e re is clearly


p re s s u re to get the p l aye r back to his sport as

involve s eccentric l a n d i n g .

( l i fting



we ight) .



act i vati n g t h e s tretch

soon as poss i b l e . Can you also comment on

retl e x . and concentric push o fr. T h i s acti o n o f landi n g

h ow certa i n strateg i e s , such as the s u rgeon

on t h e toes a nd p ush i ng o ff q u i ck ly is u s e d w h e n skat­

ta k i ng the res pons i b i l i ty of l i a i s i n g with

ing and helps to improve reaction time, wh ic h is

ma nage ment o r oth e r p rofe s s i o n a l s , m ay be

important in a fast mov i n g sport s u ch a s h ockey


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Would you describe what precautions we re

decisions or being a ffected by such decisions ( i n this

observed during the reha b i litation for thi s

case the coach and gen e ra l manager ) . In other


p atie n ts significant st a ke h o lders may include family. .

e m p loyers and fu nding bodies . The benetits of s h a ed r

• C l i n i cian's an swe r

decision making

Tom ' s tre atment was d e s ig n e d to 'push the envelope'

are i ncreasingly being recogn ize d

across the hea lth p rofe ss i o n s ( Ersser a n d Atkins,

of he al i n g a n d prov ided no adverse signs and symp­

20(0) and d e vel op i ng expertise in manual t h era py

toms a p pear e d he was c ontin u a lly pushed . Red flags.

requires that practitioners acqu ire these skills.



b a ck o ff '

The st rateg i c i n trod u c t i o n o f plyometric exer­

o n tre a tment included increased pain. p er s is t en t sti ff­

w h i c h led the p hy s i c a l thera p ist t o m o d i fy or

cises h igh l ig h ts the specilk ity of tra i n i n g req u ired



ness and strength plateau ing. Other factors that c ou ld

when wo rki n g w i t h hig h- level a t h letes such

h ave been incl uded but were not factors here include

patien t . Even wh en postoperative protocols exist

t he

swe l li ng i n the j O i n t or tissues. c on t i n u ed m u scle


b u rn i n g

a pp roach to re h abilita t i n g




crepi tus

a nd fa sciculations or



re b a b i l i tation




tbis type o f repa ir).


c a s e n icely h i g hl igh t s how individ u a l p a t i e n t treat­

cramps in muscle.

ment selection and prog ression decisions are b ased on t h a t patien t's p ar tic u l ar presen t a t i o n a n d bis

• C l i n i cal

response to treatme n t s . as determined by tbe

reaso n i ng c o m m e ntary

on goi n g reassessment of spec ilk phys ical impa ir­

In re s po n se to q u e st i on 3, the c l i n ic ian has p rov i de d a nice example of collabora t i ve reasoning in ac t ion


m en ts and fu nction a l ind icators. Physiotherapy

ex p er t i s e in t h i s setting requi res s p eci a l su rger y ­

Collaborative reason i n g . as p or trayed in Chapt e r 1 .

a n d sport-specillc knowled ge in order to i m p l e

is the shared decision m akin g between patient.

ment a n d progress the optimum

health care p rov id er s (in this case t he p hys i c al ther­ -

apist, orthopaedic s u rgeo n and the ath letic tr ai n e r ) and relevant others

c o n tr ib uti ng

to management


s t rate gies for maxi m u m speed of recovery with o u t

. compromising t h e h e a l i n g tissues or i n c u rring


r i s k of recu rrence.

but Tom felt he could o v e rco me these t h in g s and com­ pete w i th n o d i ffic u l ty.

At 1 m o n t h fol lowing Tom ' s return t o play ( 1 6 weeks) . he s til l had not reached his full po te n tia l foll owin g the

i nj u ry. This was evident to



b oth


m u st be remembered that

the maj o r i ty o f athletes are y o u n g . ver y h ea lthy and

very good at t heir sport. with h i gh expec tations espe­

the coaches and the

Ci ally in pro feSSi o n a l sport. To receive a maj o r i nj u ry

medical team . Tom was not performing at the level that

o lten ma k e s them face their own mortality, and many

he was at before th e inj ury. Al tho u gh he could skate as fast. he was ten ta tive in his p lay making and showed h esita tion when there was the potential of b o d y con­

people h ave d i ffic u l ty dealing with t hi s a l o ng with

tact. Tom stated that he felt the knee was fme al th ough he stUI h ad some ' twinges' in the Imee when p l ayin g . As


pre c a u ti on against swelling or pain . To m received

ice to the lmee for 1 5 m inu tes after every practice. game or worko u t . From the begi nning. he was told by tbe p hy s i c a l th erap i s t and the orthopaedic sur ge o n that i t wo u ld be a long-term process and that the heal­ i ng wo uld probably tal<e at lea s t a ye ar to be c om p leted ,

t heir i nj u ry Tom fo und that a l t h o u g h h e was ab le to ska te and play he was n o t able to bring his level of play up to t h a t he h a d prev iously achieved . al t ho ug h there was i m p r ove m ent Psycho logically this was very hard fo r To m , but the the rapi s t conti nued to work with him to try to en s u r e that he wo u ld r e t u r n to hi s fu l l level of a b i l i ty. At 24 weeks To m had a l most returned to h is fu l l pote nti al . Howeve r. a spo r t psy­ c hologist was also e n listed to help h i m to deal with h i s apprehension a nd fr ustra t i o n .

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� J _



I n h i n d s ight a n d w i th the pres e n c e of the early i n d i cato rs of psyc h o l ogical fa ctors, do yo u th i n k

• C l i n i cal

that t h e spo rts psyc h o l ogist s h o u l d h ave been

The key word from a reasoning perspective i n this

co n s u l ted soon e r i n th i s parti c u l a r cas e ?

answer is ' reflection ' . It is often incorrectly

that experts have such good knowledge

• C l i n i c i an 's an swe r

assumed a n d vast

experience that they do not make ' mistakes' . Every

On re n ectio n , it pro b a b ly wo u ld h ave been of benefit to consu l t a s ports psyc h o l ogist e a rlier in the rehabi l i ta­ li on programme. O n e th i n g t h is case has i l l ustrated to me, n ow t h a t I watch more cl osely fo r these a d verse psyc h o logical re action s . is how fragi le i s the psyc he of many a t h l etes . wh ich in m a ny ways i s surprising given the h i g h demands a nd someti mes viciousness o f con tact/co l l ision sports . At hletes. probably more t h a n most pa tien t s , require

reason i n g co m m e ntary


great deal of posi tive

rei n fo rcemen t o n how they are prog ressing. The fe ar

exper t repre se n ted in t h is book would certainly dis­ count this assumption. Experts do make mistakes . but because they te nd to possess supe ri or meta cog­ nitive ski l ls


including continual r e flec t io n


th ey

learn from their patient experiences, continually bu ilding and refining their k n ow l edge and ski lls for use with future patients. Experts have superio r knowledge, not superior memory. They

have supe­

rior knowledge because their reasoning is o pe n ­ minded, c r i tic al

and reflective.

of losi ng their liveli hood ( a n d sometimes high sala ries) is very re a l to them.

• Refe rences Ersser. S ,J. a n d A t k i n s . S.

( 2 000 ) . C l i n i c a l

re aso n i n g a n d patien t - c e n tred c a re.

I n C l i n ical Reaso n i n g i n the Hea l t h Profess i o n s 0 . H i ggs a n d �,! . Jones. cds . ) pp. 6 8 - 7 7 . Oxford : Bu tterworth-Heineman n . Kenn edy, r C . ( 1 9 7 9 ) . T h e Inj ured Adolesc e n t K nee.

B a l timore. M D :

W i l l i a m s & Wi l k i ns.

D . L . a n d Ptak. R.A. ( 1 9 6 6 ) . The rationale f o r pro l o n ged

Kottke. p.r . Pa u l ey.

Reha b i l i t a ti o n . Ed i n b u r g h :

Ch u r c h i 11- Li v i ngsto n e . G rifr m , L . y. ( 1 9 9 5 ) . Rehab i l i tation o f the Inj u red K n ee. Lo ndon: Mos by.

R.A. and Bu tler, R . A . ( 1 9 8 1 ) . B i o physical

s t retc h i n g for cor rection of s bor teni n g

fac to r s i n range of motion exerc ise.

o f connective t i s s u e . Arch ives o f

P hy s i c a l Sports

P hysical Med i c i n e a n d Rehabil itati o n . 4 7 . 3 4 5-3 5 2 . Muller. W. ( 1 9 8 3 ) . The Knee: Form, Fu nction a nd Ligament Reconstruction . Berl i n : Springer-Verlag.

F u rt h e r read i n g

El l enbec ker. T.S . ( 2 0 0 0 ) . Knee Ligament

Sapega. A . A . . Qued e n feld. T. e . . Moyer.

Hughsto n . r. C. ( 1 9 9 3 ) . K n e e Liga m e n ts :

Mos by. W. N. ( 1 9 9 1 ) . Ligame n t a n d

I n j u ry a nd Repai r. London: Scott.

Ex tensor Mec h a n i sm I nj u ries o f the l(n ee. Lo n d o n : Mos by:

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Med icine 9. 5 7- 6 5 .


Patellofemoral pain in a professional tennis player


Jenny McConnell


A 27-year-old professional tennis player presented

This was because the magnetic resonance imaging

with a o-month history of gradually worsening left

(MRI) scan showed a bone bruise on the lateral side of

knee pain. The player complained of anteroinferior

the trochlear notch. The enforced rest on crutches had

pain. as well as lateral knee pain. The lateral knee

resulted in marked atrophy of the quadriceps muscle

pain. which only became a complaint 6 weeks ago

but had not changed his inferior pateiJar symptoms to

when the player changed orthotics. was extremely

any great deg ree. a lthough the lateral symptoms had

severe . particularly when

the knee

was flexed in both

subsided. He was now very depressed as his tennis

the stance and swing phases of gait. The pain was so

ranking was sliding and his knee was not improving.


He was unsure of his future and was contemplating

It was less intense at the time of presentation. but he

retiring from tennis on medical grounds. but this was

had not been stressing the knee at all as [or the past

not his preferred option.

severe that he was forced to pull out of a

month he had been

� j .

non-weight bearing

on crutches.


From the information elicited at this early stage. were you at all able to recogn ize a clinical pattern in his initial presentation? What were your principal hypotheses for the two pains. and were there any other potential sources that you considered and planned to test through further examination?

was suggestive of an iliotibial band (ITB) friction syndrome. because the player was complaining of the lateral knee pain during flexion. even unweighted flex­ ion. of the lmee. In the l1exed position of the knee. the ITB is under tension. and if tight it wUI rub over the lat­ eral femoral condyle. causing a tendonosis of the ITB or


inl1ammation of the intervening bursa (Brukner

• C l in ic ian 's an swer

and Khan. 1993). Additionally. the change in orthotics

From the initial part of the history. it was clear that the

structures in the lower extremity and place more stress

may have been sufficient to alter the balance of the

athlete had two different types of knee pain. which

on the ITB. If the orthotic is made from a rigid or semi­

could possibly be related. The more recent lateral pain

rigid material. then shock attenuation at the foot may


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b e poor. particularly i f the p ati ent has a stiff rearfoot


(Grelsamer and McConnell.

This decrease in

Therefore. chondromalacia is a less likely diagnosis i n this case.

shock absor ptio n places incre ased stress on the distal end of the ITB. as the internal rotatory force of the

tibia. which should occur with knee flex ion . is blocked by the distal external rotatory force created by the

• Cli ni c al reasoning com m e ntary The early formulation of hypothe ses relating to the

orthotic. T he long -stan ding inferior pain could be

source of the

caused by a patellofemoral problem or patellar ten­

poten tial

donosis. More information fr om the history about the

orthotics) is evident in t h is response. In partic ular.

pains (e.g.


patellar te ndonos is)

( e .g.



a nd


behav i our of the pain is required before a provisional

the identification of ini tia l cues ( th e location of the

diagnosis can be formulated.

lateral pain in an elite

The MR1


a nd

its behaviour)

fracture .

appears to have tr iggered the recognition of a famil­

Whether there was underl yi n g chondromalacia and

iar clinical pattern. i.e. ITB fric tion syndrome.

whether it was contributing to the patient's symptoms


could not be de fin itely determined at thi s stage. The

l argely d epen d ent on previous clinical experience

state of the articular cartilage can only be assessed

with similar presentations and is. therefore. not usu­

with a T rweighted image on MRI. sO it is poss ible the

al ly an important feature of the clinical reasoning of








patter n

recognition is

patient had some chondral degeneration. w hic h is

nov ice practitioners but is heavily re lied upon by

common in te nni s players. However. recent evidence

experts. such as in this case. It is important to high­

has suggested that articular cartilage degeneration is

light that the clinician has also drawn on informa­

usually asymptomatic (Dye et al. .

tion from

1998). Nonetheless.

symptoms a clin ician would need to be aw are of to

knowledge gained

indirectly trom the

li terature and that this has been effectively inte­

determine the presence of articular cartil age degene r­

g rated

ation include swelling and l ocking . as well as pain.

own person al clinical experiences.

with knowledge di r ectly gained from her

The inferior knee pain did not keep the patient awake

medication he was t akin g ) did not have any effect on

at night. but it did cause him con siderable discomfort

the symptoms. He had never taken steroids. nor

when he was standing and going up and down stairs.

experienced any symptoms in the hips. feet. lumbar

The knee did not lock. click or give way. but it had been

spine or any other joint. T his "lAlas his first episode of

swollen . The swelling was mostly infrapatellar. but

left knee pain. He had experienced medial pain in the

he did occ asion ally notice minor joint effusion after

right knee 5 y ears ago. which improved w ith the fit­

playing. When the player was first aware of his knee

ting of l1exible orthotics in his shoes. The orthotics

symptoms 6 months ago. he had been play i ng on grass

were prescribed for his forefoot va lg us d e formit y.

and was running back from th e net to reach a high

which caused excessive pronation at mid s tance . He

backhand smash. He won the point. but as he made

used flexible orthotics until recen tly . when a computer­

contact with the bail he felt a pinching sensation distally

gener ated pair was mad e . It was after this that the left

in his knee. That evening the knee was slightly puffy. so .

lateral knee p ain developed.

he iced it and sought some treatment. The treatment

His general health was good with no rec e nt weight

consisted of elec trotherap y (ultrasound and in te rferen­

loss. and the only surgery he had und er go ne was an

tial curren t ) . as well as quadriceps muscle stretching

appendectomy 3 y ears ago. The p la in r adiog raph of

and s trengthening .

the knee was unremarkable. but the MRI showed a

The quadriceps strengthening

involved straight leg raises and isokinetic leg extension.

bone bruise on th e trochlear n o tch . It was this finding

The Imee initially was only intermittently p ain ful.


that prompte d the orthopaedic surgeon to put the

weeks of treatment it had worsened trom being

patient on crutches. However. as the p atie nt vvas not

after 3

painful only when the p l ayer was returning low volleys.

improving and becoming increasingly anxious with

to being painful during aU aspects of play.

each day away from training. the surgeon referred the




st eroida l anti-inl1ammatory

reporte d



pa tien t to m e .

medication (the only

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� I r


What was your interpretation of the worsening of the athlete's knee pro blem? Did the additional information regarding the mechanism of symptom onset enable you to narrow your hypotheses further regarding the source of the inferior knee pain?

patient's symptoms in so far as the patient was com­ plaining primarily of inferior patellar not retropatel­ lar pain. which was the location of the bone bruise. In changed the patient's inferior patellar symptoms at

At this stage, it became clear that rapid ell.1:ension of the knee (retrieving the high backhand smash) produced


The bone bruise may have been incidental to the

addition. being on crutches (rest) for a month had not

• Clinici an's answer the

• Cl inician's an swer

pain and that the treatment may have been

instrumental in worsening the symptoms. Therefore. the most W<ely diagnosis for the tennis player's inferior patellar pain was an irritated fat pad. because it was trig­ gered initially by a rapid ell.1:ension manoeuvre. mani­

all. which would have been anticipated if the symp­ toms were ariSing from the bone bruise.


How did the working hypotheses you entertained influence your planning of the phy sical examination?

fested returning from flexion (returning a low volley)

• Cl i nician's answer

and was also exacerbated by treatment. It is unW<ely

At the completion of the history. the provisional diag­

that the electrotherapy part of the treatment was the


nosis for the patient's lateral knee pain was ITB friction

but it was possible that the quadriceps work.

syndrome and the provisional diagnosis lor the infer­

particularly the strengthening exercises, may have con­

ior knee pain was an irritated infrapatellar fat pad.

tributed to the increase in symptoms. The strengthen­

Both conditions are usually the consequence of poor

ing exercises emphasized extension of the lmee, which can cause an increase in symptoms when the fat pad is inflamed. Once the fat pad is inflamed, forced extension of the knee, which causes a posterior tilting of the infer­

patellofemoral biomechanics. such as a tight ITB. poor pelvic control and excessive loot pronation. The aim of the physical examination was to test further possible sources of the symptoms and to determine

ior pole of the patella as a result of the attachment of

which of the biomechanical variables were contribut­

the patellar tendon on the tibia. may further irritate the

ing to the patient's symptoms. so that treatment could

fat pad. The fat pad has been found to be the most pain­ sensitive structure in the lmee (Dye et aI.,


At this stage. the dilTerential diagnosis of patellar ten­ donosis could be largely discounted for three reasons. 1. There had been no reported increase in eccentric loading of the quadriceps during training or match play. Tendonosis is usually provoked by an increase in eccentric loading of the quadriceps muscle. 2. The particular quadriceps exercises given should not have markedly worsened the symptoms as there is less tension in the tendon during knee extension and straight leg raise than during eccen­ tric activities. 3. The MRI did not demonstrate any degenerative change in the patell ar tendon,

which usually

occurs when tendonosis is present.


be directed accordingly. There were several examination procedures of par­ ticular importance with respect to testing the work­ ing hypotheses: • the Thomas test, which assesses the tightness of the tensor fasciae latae (TFL). as well as the rectus femoris and psoas muscles • Ober's test. performed in side lying. usually elicits pain when the lmee is flexed and extended from o to


degrees if the


is tight; this is because it

flicks over the lateral femoral epicondyle causing inflammation and pain • when the condition is acute, the lateral femoral epicondyle is often quite tender on palpation and the fat pad is frequently enlarged and when pal­ pated feels quite 'boggy' compared with the other

What weighting did you place on the MRI finding

side, with the patella buried in the fat pad such that

of a bone bruise?

the inferior pole is difficult to palpate

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• inferior patellar pain is often exacerbated by an active

quadriceps contraction in full extension, as well as during passive extension performed by the therapist.

• Clin ical Following

tendonosis), often an absence of an expected rm din g


A plausible pathomechanical hypothesis consistent

with the clinical presentation and with scientific understanding of kn e e pathology lends further

reasoni ng com m entary

weight to the favoured diagnostic hypothesis.

The assessment of the MRI finding of



early generation of diagnostic hypotheses based on recognition of initial cues from

bruise demonstrates testing of a diagnostic hypo­

familiar clinical patterns, the information obtained

thesis (bone bruise as both source of the symptoms


from subsequent enquiry strategies (e.g. the worsen­

and associated pathobiological mechanism) with

ing of the problem)

is used to test the competing hypotheses. The picture that unfolds is one in which

other findings from the history (location of pain and

there is growing evidence that supports one hypoth­

hypothesis. Consequently, the hypothesis has been


rejected and the main supporting clinical evidence


fat pad) and other clinical data that

tend to ne ga te


the alternative hypothesis (patellar

response to rest), which are found not to support the

(MRI scan) reinterpreted as an incidental finding.

PHYSICAL EXA M I N ATIO N of lmee i1exion when descending stairs, during which

Observati on Examination of the patient in standing revealed an internally rotated femur, tibial varum, an enlarged fat

t he

trunk lateral flexion was even more pronounced.

pad on the lert side, stiH rearroot and compensatory

Passi ve exam i nati on proc edures

midfoot pronation. The rearfoot was deemed to be stiff

In supine lying, the inferior pain was slightly elicited

because the talus was quite prominent on the medial side when the patient was viewed from the front but the calcaneum was straight when viewed from behind. If the talus was prominent on the medial side in standing. the calcaneum should be everted if the

rearfoot had adequate mobility. The left quadriceps muscle, although smaller than the other side, was well dermed. The ITB appeared taut on both sides. The glu­ teus maximus muscle was well developed, but the glu­ teus medius muscle was suboptimal in bulk bilaterally. The patient was examined dy namically

on passive extension overpressure of the knee. All other passive movement tests were clear, including i1exion overpressure (straight and with an abduction and adduction bias), McMurray's test for the menis­ cus, and Lachman and pivot shift tests for the anterior cruciate ligament.

M usc l e l ength tests The TFL muscles were found to be bilaterally tight dur­ ing the Thomas test. The iliopsoas, rectus femoris and

the effect of muscle action on the static mechanics, as

TFL muscles may all be tested using the Thomas test

well as to reproduce symptoms. The least stressful activ­

(Hoppenfeld, 1976; Kendall and McCreary,

ity of wallting, which did not reproduce any symptoms,

perform the Thomas test, the patient stands with his

1983). To

was examined ftrst. There was minimal knee i1exion evi­

ischia touching the end of the plinth. One leg is pulled

dent at heel strike on the left side during walking. The

up to the chest to i1atten the lumbar lordosis, and then

patient also demonstrated increased trunk side Ilexion

the patient lies down on the plinth keeping the Ilexed

on the left side during the stance phase of gait, often

leg close to the chest. The other leg should be resting

suggestive of wealmess of the gluteus medius

and per­

such that the hip is in the neutral position (i.e. on the

haps more proximal weakness of the trunk In this case,

plinth, at the same width as the pelvis) and the knee

it was probably poor gluteal control contributing to the

should be i1exed to 90 degrees. If the hip is in the neu­

problem rather than proximal trunk wealmess, as the

tral position but the knee cannot be i1exed, then rectus

patient was regularly doing Pilates exercise classes as

femoris is tight. If the hip is i1exed but lying in the

well as abdominal strengthening activities in the gym.

plane of the body, the iliopsoas muscle is tight. If the

The inferior patellar pain was reproduced at

hip remains l1exed and abducted, then TFL is tight.

60 degrees

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Lack o f flexibility o f T FL can b e further conflfmed in side lying by Ober's test (Brukner and Khan, 1993: McConnell, 1996). The Thomas test needs to be per­ formed on both legs so a comparison between legs can be made. The other muscles acting around the knee were more than adequately flexible. In fact, the ham­ string muscles were almost too flexible, with a straight leg raise of 100 degrees bilaterally.

Flexibili ty of l ateral structures The side-lying position was used to assess the l1exibility of the lateral structures. notably the lateral retinacu­ lum (superficial and deep fibres) and the ITB. To test the superficial retinacula structures, the knee was Ilexed to 20 degrees, from where the patella


moved pas­

Sively in a medial direction. The lateral femoral condyle was not readily exposed, indicating the superficial reti­ nacula fibres were tight. The deep fibres were tested

Pate l lar posi ti on

with the patient in the same position. The slack of the

Although determining the position of the patella

anteroposterior pressure was applied to the medial bor­

relative to the femur has been found to be somewhat

der of the patella. The lateral border did not move freely

unreliable when performed as an isolated procedure

away [rom the femur, which indicated that the deep

glide was taken up in a medial direction and then

(like most manual palpation tests), it still remains an


fibres were also tight. Tightness of the ITB was further

important part of the examination process and can be

conflfmed by Ober's test (McConnell. 1996).

used to help to guide treatment choice (McKenzie and

test. the underneath hip and lmee are Ilexed to stabilize

Taylor, 1997; Potter and Rothstein, 1985; Watson et al.. 1999). The left patella was laterally tilted and displaced, with the inferior pole tilted posteriorly into



the pelvis. while the knee of the upper leg is flexed to 90 degrees and the hip is abducted. externally rotated and slightly extended. The thigh remained abducted

the fat pad. This was determined by examining the

when the leg was released, indicating tightness of the

patellar position relative to the trochlea. An optimal

band (McConneLl. 1996).

patellar position is one where the patella is parallel to the femur in the frontal and sagittal planes, and the patella is situated midway between the two condyles when the knee is flexed to 20 degrees (Grelsamer and

Other examination procedures Testing of hip extension and external rotation range

McConnell, 1998: McConnell, 1996). The distance

of motion in prone lying revealed tightness of the

from the middle of the patella to the medial femoral

anterior hip structures. The patient was examined in

epicondyle was greater than the distance from the

a figure of four position, with the underneath foot at

middle of the patella to the lateral femoral epicondyle,

the level of the tibial tubercle. The distance of the left

indicating a laterally displaced patella. The posterior

anterior superior iliac spine to the plinth was 10 em,

edge of the lateral border of the patella was difficult to

whereas the right was only 6 cm from the plinth.

palpate, with the medial border sitting further from

Additionally, the stiffness of the subtalar jOint was

the femur, thus indicating a laterally tilted patella.

confirmed in this position. The lumbar spine was not

There was also a posterior displacement of the inferior

palpated at this time because there was nothing in the

pole of the patella.

history to indicate lumbar involvement.

� I J -



How did the initial observation of the patient fit

usuaUy associated with a tight ITB and poor function­

in with your working hypotheses?

ing of the posterior fibres of the gluteus medius muscle. Tightness in the ITB results in overactivity in the TFL and diminished activity in vastus medialis

• C l inician's answer

obliquus (VMO) and the gluteus medius posterior

Patellofemoral dysfunction may arise from abnormal

fibres. The faulty alignment pattern remains because

gait patterns, primarily caused by poor dynamic lower

the muscles in a shortened position (usually two joint

limb mechanics. Internal rotation of the femur is

muscles) are readily recruited and are strong, whereas

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muscles in a n elongated position (usually postural

the lack of knee flexion at heel stru<e, causing the


patella to further irritate the inl1amed fat pad








tight ITB, which the patient rests on when

(Sahrmann, 2(02). A patient with a shortened ITB often demonstrates excessive medial rotation of


standing on one leg with


fully extended knee.

hip during the stance phase of gait, which means that

further irritating the fat pad

the pelvis on the opposite side drops,

tightness of the anterior hip structures, which



external rotation,

Trendelenburg-like appearance (Sahrmann, 2002).

decreases hip extension and

Tills hip movement will increase the dynamic quadri­

thereby decreaSing gluteus medius posterior



angle (D'Amico and Rubin, 1986) and hence

fibre control and increasing TFL tightness

increase the potential for patellofemoral pain.

increased stiffness of the subtalar joint, thus

Initial shock absorption should occur with knee

transferring the shock absorption further up

l1exion of 10-15 degrees, because the loot is supinated

the kinetic chain to the pelvis: if the subtalar

when the heel first strikes the ground. This knee

jOint does nottake some of the load. the load is

flexion, which is accompanied by internal femoral rota­

then transferred from the foot through the

tion, should immediately be followed by rapid prona­

knee, which also does not absorb the stress. up

tion of the foot. Reduced knee l1exion on heel stril<e

to the pelvis, causing a 'jarring' at the knee

means that the ground reaction force is not minimized

that loads the inl1amed fat pad

at the knee, so greater load vvill need to be tal<en

lack of pelvic control. increasing the internal

through the foot (Powers et al., 1997). If the foot is also

rotation of the

stiff, as in this case, then the shock absorption must

the dynamic

occur at the pelvis, with increased anteroposterior tilt

lower extremity and increasing Q angle.

• ITB friction syndrome causing the lateral pain:

or rotation movement or lateral l1exion movement. The

supportive findings included: tight ITS, so it 'rubs' on the femoral epicondyle

normal pelvic range of motion during gait is 4 degrees of lateralilexion, 7 degrees of anteroposterior tilt. and

laterally tilted and displaced patella, which

10 degrees of rotation (Perry, 1992). Reduced knee

indicates tightness of the ITB because most of

rJexion on heel strike may also result in poor inner­

the lateral retinaculum arises from the ITB

range eccentric control of the quadriceps muscle.

new rigid orthotics. which further minimized

As this patient presented with internally rotated

the shock absorption through the foot. provid­

femurs, tibial varum, a high-arched foot and 'locked

ing to the knee an externally rotating distal

back knees', then his shock absorption was diminished

force on an internally rotating proximal force

at the subtalar joint and the knee: consequently, he

increased stiffness of the subtalar joint

had to absorb more shock at the pelvis. This caused an

poor pelvic control.

increase in the lateral tilt and rotation of the pelvis as his hip external rotator and abductor muscles were inadequate for controlling his pelviS. The locking back of his knee


further aggravated his fat pad problem.

These last three findings are important because load is transferred through the lower extremity to the pelvis if shock absorption is reduced through the foot; as a result, there will be increased dynamic pelvic movement. The lower leg needs to rotate internally on

Could you please describe your principal

heel strike: however,

diagnostic hypotheses at the end of the

examination ( with supporting and negating


rigid rearfoot and an unforgiv­

ing high corrective orthotic will create an external

evidence). including any significant biomechanical

rotatory moment, so the ITB attempts to absorb the

or other factors contributing to the problem?

force [rom these two opposing moments. If the pelvis exhibits an increase in lateral tilt, then the TFL tight­

• Clin ician 's answer

ens, decreasing its l1exibility. This can affect the distal course of the structure, that is the distal end of the

The principal diagnostic hypotheses were:

ITB, predisposing the patient to ITB

• fat· pad irritation causing the inferior pain: sup­ portive l1ndings included: the

enlarged fat pad

- the posterior tilt of the inferior pole


syndrome .

Bearing in mind your response to the previous question. what then were your specific goals for treatment. both short and long term?

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• Clinician's answer

• Clinical reasoning commentary

The specifi c short-term goals were to:

The p r ocess of

• minimize t h e fat pad irritation by unloading the painful structures



generat i n g and prioritizing whatever


it may



requires the ability to recognize salient clinical

• improve the mobi l ity of the anterior h ip structures

fi nd i n g s retain those t1ndings in short-term mem­

to increase hip extension and external rotation;

ory. and synthesize the patient data to de termine

this will decrease ITB tightness

the dom inan t hypothesis. As discussed in Chapter 1. a number of clinical fe a tu re s will provide sup­ porting and negating evidence. and it is rare that a single feat u re will completely con I1rm or com­ pletely negate a pa rti cul a r hypothesis. In this

• improve gluteal and eccentric i nner range quadri­ ceps muscle control. The specific long-term goals were to: • improve the endurance capacity of the VMO and the gluteus medius muscles


response. the clinician has highlighted how all the patient information must be weighed. with

• incre ase the subtalar joint mobili ty

the s tre n gth of the supporting data ve r sus the

• return the patient to competitive tennis • teach the patient how to recognize symptoms and prov ide him wi th slTategies to self-manage his con

strength of the negating data determining the dominant hypothesis



dition to prevent recurrences.

[3'-"·II'I'43··'§U_ • First treatment Initial treatment involved loosening of the tight deep lateral retinacul a structures by soft tissue massage, while the patella was being medially tilted. The patient was

given a st retching exercise in prone ly ing

for the tight ante ri or structures (adductors. TFL. psoas, ante rio r capsule. iliofemoral ligamen t) which he was .

instructed to do twice a day for five repetit ions


Fig. 13.2

Gluteus medius posterior training. The

patient stands side-on to a wall. with the leg closest to the wall flexed at the knee so the foot is off the ground (the hip is in line with the standing hip).AII of the patient's weight should be back through the heel of


Unloading the fat pad.With the patient sitting

on the edge of the chair. the unload tape is started at the tibial tubercle and lifted out to the joint line. The soft tissue is lifted up to the patella. (From McConnell.


the standing leg. which is slightly flexed. The patient externally rotates the standing leg without turning the foot. the pelvis or the shoulders. (From McConnell,


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With the patient in supine lying tape was ap plied to ,

the patella The flfSt piece commenced at the superior .

and resting against the wa ll. The patient was instruc ted to rotate the standing leg externally



margin in the middle of the patella to tilt the inferior

moving the hip or the foot and to hold the position for

pole and the lateral border of the patella anteriorly.

15 seconds (Fig. 1 3 2). .

The second piece was also anchored superiorly at the

Once this exercise was suffiCiently familiar to the

lateral border of the patella in order to correct the

patient that be could re peat it regularly at home, dual

gli de. This was followed by a 'V' tap i ng from the tibial

channel biofeedback was commenced with

tubercle to the medial and latera l jOint lines to unload

the electrodes on the VMO and vastus lateralis

the fat p ad (Fig. 13.1), as well as another strip of tape

(VL) musc les . Em phasis was on the timing and inten­

[rom the lateral femora l condyle diagonall y across the

sity of

[1'8 to decrease the tension on the band. After the tape

patient performed small-range squats, the VMO activ­

was appl ied the patient was retested on the stairs and

ation was delayed and the VL contraction was g reater

cUd not experience any symptoms.

in mag nitude ensuring the knees were not locking

the VMO contraction. Initially

when the


Training the posterior fibres of the gluteus medius

back (being forced i n to end range extension). The

muscle in weight bearing was also an immediate pri­

patient was also shown how to tape his knee while sit­


ority for treatment, both to decrease TFL tightness

ting on the edge of a chair with the leg extended but

a nd to improve pelvic stabilit y. The patient stood on

rela xed. In addition he was shown how to massage

the left leg aga i nst the wa ll . The hip of the right leg

and stretch the deep later al retinacula structures in

was in line with the left hip, but the knee was flexed





What clinical findings led you to suspect that the

activated 5.6 milliseconds earlier than the VL. Even

VMO required retraining? In addition to your

though this fmding was statistically significant, the

own clinical experience, what evidence supports

authors questioned the functional relevance. The above results are at odds, however,

this approach?


the find­

ings of other investigators (Gilleard et aJ., 1998: Karst and Willett, 1995; Powers et aI., 1997), who reported

• Clinician's answer

that the VMO dld not rlfe earlier than the VL in asy mp­

The left VMO activity was measured relative to the VL

tomatic volunteers and that the VMO activation was

ac tivity, and this was compclfed \"'1th the ratio on the

not delaye d in symptomatic individuals. It is of interest

asymptomatic side. The VMO muscle was not activat­

to note, therefore, that Cowan et a1. (20 0 1 ) found that,

ing early enough d uring small knee bends and was

even though the majority of patellofemoral sufferers

exhibiting less act ivi ty than the VL. However, the signal

had a de l ayed onset of VMO relative to VL on a stair­

was not normalized. The issue of VMO and VL timi ng is

stepping task (67% concentrically, 79% eccentrically )

still controversial. Voight and Weider (1991) found

there were still some whose VMO activation preceded


that the rel1ex response time of the VMO was earlier

their VL activation. Additionally, these investigators

than that of the VL in

asy mpto m at ic group, but in

found that some of the control subjects (no history of

a symptomatic pate ll o fe m oral group there was a rever­

patellofemoraJ pain) exhibited a delayed onset of VMO


sal of the pattern. These fi n din gs were conflfmed by

relative to VL (46% co ncentrically 52% eccentric a lly )

Witvrouw et al. (1996), but curio us ly these investiga­

on the stair-stepping task. This study by Cowan et al.


tors found that there was a shorter reflex response time

may clarify some of the discrepancies evident in the lit­

in a symptomatic patellofemoral group relative to a


control group. Further suppo r t is pro vided by the work

researchers have found a delayed onset of VMO relative

of Koh et aJ. (1991), who examined isokinetic knee 1 extension at 250 degrees/s- (following hamstring

groups only occurs when there are sufficient subject


numbers to tease out the dlfferences. The fmdlngs of

preactivation) and


that the









to VL but others have not. The stratification of the

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some of the earlier studies may not have reached statis­

of treatment per week for 6 weeks . The treatmen t group

tical significance because there were too few subj ects

received patellar taping. fi gure of four stretc h es. ham­


Although the early li tera ture s uggests there is a d if­

string stretches gl u teal training and specific VMO train­

ference in the ratio of the

V MO a n d VL activity. with t h e V1 ac tivity bein g greater than that o f the VNIO

ing vvith a dual channel biofeedback device. The p lacebo

(Mari a n i and Caruso. 1 9 7 9 ) , more recent literature

degrees of knee Ilexion in the line of t he femur. detu ned

has not s upp o r ted

this contenti o n . Th is may be

becau se the earlier s tu d ies did n ot tromy ograp h i c


group received placebo taping, which was applied at 90 ultrasound and massage around the patella

with medi­

normalize the elec­

cated gel . The symptoms in bot h groups decrea sed . but

(EMG) data. Normalization i nvolves

the treatment group h a d a far gre a te r improvement

obtai n i ng a ratio of the recorded mus c le activ i ty a nd

(vi sual a n alogue scale, p

muscle activi ty from the maximal vol u n tary contrac­

ment scale. p



0 . 00 1 : fu nctional assess­

0 . 0 0 0 1 ) . Another interesting fi nding

than the VL in the

tion (MVC ) , which then permits the comparison of the

was t hat the VMO was lking earlier

ratio o f one muscle relative to its MVC wit h another

treatment group (both concen trica lly and eccen t ri cal ly)

muscle rela tive to i ts MVC. For example. if the reco rded

after 6 weeks, whereas the timing of the VMO in the

VMO a c ti v i ty is 50 fL V and the M VC is 2 0 0 fL V and the

pl acebo group was u n changed after th is time (i .e. it

measured VL activity is

remained delayed compared wit h the VL) .

100 fLV and the MVC is

400 fL V. then the ratio VMO : V1 is 1 : 1 . There has been so me d iscu ssion that normalization i s a ffected by the presence o f pain , wh ich will mask d i ffere n ces because there could be error i n the MVC and this may appear in

• C l i n ical

reason i ng com m entary

The use of both research- and experience- based evi­ a n swer. Expert clin icians. this clinician. routinely consider the t wo

the error o f t he recorded EMG ( Ya n g and Wi nter,

dence is apparent in t h is

1 9 8 3 ) . There h a s also been some deb ate about the rel i ­

such as

abi l i ty of t h e m aximal con traction . castin g doubt o n

types of

the no r m a l iz a ti on

though the evidence may not always be in complete

process. Howard a n d Enoka ( 1 9 9 1 )

in their decision making. even

e videnc e

fo u n d that there was considerab le vari ation i n t h e

harmony. However. it is a n error of clinical reason ing

MVC of the VL EMG , e v e n t h o u g h t h e force exerted

to take <my single research fmding in isol a t i o n

by the

leg remained constant


I n terestingly. Yang



it is

finding. When research fi n d ings

lor a single clinical

wit h skilled rellectivc c l i n ical experience.

a nd W i n te r ( 1 9 8 3 ) fo u n d t h a t the averaged recti­


fied EMG had a coe ffi c ie n t of variation ( s ta n da rd

the practice strategies in question shou ld nol simply

at odds

de v i a t i o n/ me a n ) of 9 . 1 % within 1 day a n d of 1 6 . 4 'Yo

be discarded . Rather. further critical rellection on the

be twee n days.

c l inical use of those s trategies must be un dertaken.


rece n t


controlled trial of

double-bli n d .


a lo n g with further

research, possi bly with grea ter

intervention programme. similar

attention to various su bgroups . which may respond

to that received by the ten n i s pl ayer. showed that the

differently. Here. the c1 i n ician's c ritic a l awareness of


treatment group d emonstrated Significantly


improvements i n pain and functi onal activities than the placebo group (Crossley et a1 . , 2 0 0 2 ) . There patients in each g roup

were 3 6

an d all patients received 1 hour

E1l",gi-'itghi·&i·fB§;·'§"_ The patient returned after a week

and was cons i derab ly

improved: he was not experiencing any p ain on sta irs and was a n xious to start playing tenn is a ga i n . His activ i ty relative to hi s VL activity improved . but it


had somewh at

w as stilJ del ayed in onset a nd w a s of

l e sser magnitude as measure d on the biofeedba ck

the quality of the research evid e nc e and her willing­ ness to reta i n


open mind on this whole issu e

(which is as yet still clearly u nresolved ) is



of cli nical expertise.

machine . A n inhibitory VL taping was

firmly app lied to

the thi g h to en hance VMO activ i ty (Fig. 1 3 . 3 ) . This imme dia te l y

decreased the VL activity. resu l t i ng i n

VM O becomin g more active. After 2 0 rep e tition s o f the small squats , the patien t began t o feel fatigu e

in the

VMO region . At subseq uen t visits. fur ther fm e tu n i ng of


quadri ceps con traction occurred . with the patient

Copyrighted Material


the calcaneu m being moved l a te r a lly. This position was a dopted to sim u l a te the mo m e n t immed i a tely after heel s trike when the s u b t a lar joint should be pronat ing. A fter s i x v i s i ts ( o v e r a period of 2 m ont h s ) the VMO was ac t i v a t i n g earlier than the VL a n d was se v e ral t i mes g rea t e r in magn itu d e . The gl u tea l exercise had been progressed to 30 s e c o n d s . with the patient prac­ tising in front o f a mirror st a nd i n g o n the left l eg a nd r a pid ly moving the righ t leg back and for t h . while keeping a s t ab le pelvis. He wa s a l so m a i n t a i n i n g a s t ea d y p e l v i s w h i l e l ow e rin g his r i g h t leg d own off a s m a l l s te p a n d re t u r ni n g b ack up to t h e s tep. He re p e at ed this exercise slowly 20 t i me s wi t hout paus­ ing i n order to i n crea s e the e n d u r a n c e of t h e VMO a n d g l u t e a l mu s c u l a tu re . A fter 3

Fig. 13.3

m o n th s t h e p a tient w a s b a c k p la yi n g tour­

n a m e n t ten n i s . His k n ee was still t a p e d for pl ay in g , I n h i b iting the vastus latera l i s . Th i s i nvolves

apply i ng three p i eces of fi rm ta pe from m i d-thigh a n t e r i ­ orly, passing laterally to m i d -t h i g h posterio rly. The soft tissue is fi r m l y c o m p ressed over the vastu s lateral is a n d t h e i l i o ti b i a l b a n d . ( F ro m M c C o n n e l l , 2002.)

pra c ti s in g s i de way s movements . and simu lated fore­ h a nd . backhand a n d se rv i c e manoeuvres. The s u btalar j o i n t was mobi l ized in side l y i n g . wit h the foot in ne u ­ tral ( plan targ rade). the tibia and tal u s st a bil i z e d , an d

but n o t for daily a ct ivit i es . A t t h is stage, the ac t i v i ty

of VMO r e l a t i ve to the V L was fo u r t i m e s grea ter. a s measu red on a d ua l c h a n n e l biofeedback dev ice. The p a t i e n t was n o t experie n c i n g a ny pain o n repeated one- leg sq u att i n g a c t i v i t ies b u t was fe arfu l about p a i n ret u r n i n g w h e n he wen t b a c k to tennis. The patien t p e r s p i r e d g re a tly when p l ay i n g so the tape h a d to be re a p p l ied d u r i n g h i s m atches . It took a fu r t h e r 3 m o n t h s before the p atie n t felt s u ffi ciently c o n fi d e n t t o pl a y w i tho u t tapi n g . the



T h e re appears to be some psychosocial issues with this athlete's presentation. Could you e l abo rate on any of th ese you considered to be clinically significant? What strategies

(if any)

d id

you employ to manage this aspect of the problem?

• C l i n i c i a n 's an swer The pla ye r was very c o nc e r ned a n d anxious a bo u t h i s r an kin g and h i s fitness , whic h he fe l t was det eri or a t­ i n g by th e second . It was i m p e r a t ive th a t I worked in closely with the p l a y e r' s fi tness coach. w h o was w r i t­ ing programmes to mai n t a i n c a rd iova s c u l a r fi tness a n d upp e r b o dy s t r en g t h d u r i n g h is r e h a b i l i t a t io n . Together, we devised a re h a b i l i ta ti o n p l a n for the

p laye r i n which he could see the s h o r t - t er m a n d l o n g­ term goal s and how we were goin g to m e a s u r e them (principally m e a s u r i n g pai n and EMG a c t ivity ) . In i t i a l l y th e pl a ye r was d oi ng q u i te a b i t of water running, w h i c h n o t o n l y i n creased h i s he a r t rate but also h elped to m a in ta i n his runn i n g fo r m . Other car­ diovascu l a r wo rk i nc l u d e d c yc l i n g on a st a tio n a ry b i ke (which became p a r t of h is prog ramme) as soon as he had no pain d o i n g that activity. The co a c h a nd I al s o exa m ined some of the p l a ye r ' s techniques from old v ideo foo tage. We were par t ic ular ly interested in the o pen stance fore hand and discu ssed strategies w i th the p l a y e r to m i n i miz e p i v o t in g ex c es s iv ely a ro u nd the knee a nd use m o re t run k r o t a t i o n . Th e s e tec hn i q ue a dj u s tm en ts were worked on d u r i n g the re h a b i l i t at io n of tbe kn ee .

Copyrighted Material


At t h e end of the second month , t h e player com­

profession a l s . In this

menced i n te r v a l tra i n i n g : short sprints fo l l owed by


the i mportance that

t h e expert clin ician p l a c e s o n a h o l i st i c and team

l o n ger s l ower r u n s . Slow ly, plyometric tra i n i n g was

approach to the patien t's problem is wel l illustrated .

i n t r od uced into the train i n g progra mme a s t h e core

Consideration is gi ven to the patient's p sych os o c ial

stab i l i ty improved . p a r tic ula rly g l u te a l work.

issues . maintaini n g h i s general Iltness and upper body m u s c le stren g t h . and involvement of the

• C l ini c al

coaching staff. such as in addressin g his

reasoning com m e n tary

t e c h n ique The p atien t is .

Manual the rap i st s are often c ri t i c i se d for relying on

a l so

playing in

very m u c h involved


his reh abi l i tation progranune a n d has been empow­

tissue-focussed and reduct ionist approach to chro n ic

ered with the mea ns a n d re sp o n si bi l i ty to make a

muscu loskeletal prob lem s

and for inadvertently

significcmt contribution to his own recovery. Suc h a

encouraging patien t passivity a nd dependence on

comprehensive approach to rec a lcitra n t c l i n ical

the t herapist. They are

a l so

problems is crit ical to a s u cce s s fu l outcome and only

often g u i l ty of wo r k i n g

in isolation and fa i l ing to seek appropriate input

serves to enhance the

i n the managemen t p ro c e s s from othe r relevant

in the eyes of their colleagues and patients.


stand ing of m a n u a l th erapis t s

exercises consis ting of the s ta ndi ng glu teal exerci s e


small-r a n ge squats. and the figure of four stretc h in When the t o u r came back to Austra l i a . the patient

prone lyi ng. His VMO activi ty was still fou r ti mes t h a t of

returned for review. He was stil l doing his maintenance

the VL a n d he h ad been sym ptom free for 12 month s . -

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. .


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Self-management guided by directional preference and centralization in a patient with low back and leg pain Robin McKenzie and Helen Clare


Jamie is


3 2 year-old carpenter who -

for the past

2 years has been self-employed building houses, requir­

ing only occasional assistance. He complained of back and right leg pain radiating below the knee (Fig.


and had experienced a similar problem on lwo previous

occasions, the most recent being 2 years ago. Jcunie was advised 3 year s ago that he had


degenerated disc at

L4-LS. He refused surgery and went to



wilh a successful outcome. The symptoms had been present for 5 weeks and


commenced on the right side of his back. The leg

pain had appeared more recently. The patient believed the leg pain was getting worse with the passage of time.

right­ com pl ained

Jamie stated that the pain in the cenlre and side of his lower back was constant. He

that the pain radiated into the right buttock and thigh on performing certain movements, but these pains ceased 'when he returned to


more upright position.

His pain was worse w ith prolonged bending and sit­ ting. When driving his truck, the pain extended into the lower leg and hi s foot tingled and at times becomes 'dead'. His back and leg pain also incr ea sed if he stood erect for prolonged periods. He had particular diffi­


getting out of bed in the morning because of

increased back an d buttock p a i n . Coug hing and sneez­ ing

prod uced or increased p ai n in the rig ht buttoc k . partially

The patient noted the back pain was

re l ie ved, and the buttock and leg pain abolished, when he lay face dov.TJ1. His leg pain decreased when he walked short distances but inc re ased if w alki ng was pr ol onge d .


could then obtain relief temporarily

Fig. 14.1



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Area of patient's pa in.


he bent slightly forward. All symptoms were also

He was now taking two Digesic (dextropropoxyphen e

relieved if he lay in bed face up with his knees bent.

30mg + paracetamol325mg) table ts three times per

However. the symptoms never completely ceased in

day for pain relief. Radiographs showed slight narrow­

the back or upper thigh.

ing at L4-L5.

The patient's general health was good. there was no weight loss. and until recently he refused mectication.

REASONING DISCUSSION AND CLINICAL REASONING COMMENTA RY At this stage what were your initial thoughts!

usually be felt constantly as long as the concentra­

Which hypotheses (if any) were you considering

tion of chemicals is sufficient to activate pain recep­

with respect to the source of the patient's

tors. Pain can also be experienced constantly when


mechanically dislocated tissue (such as discal tissue) is

displaced and deforms adjacent normal soft tissues .

• Clinicians' answer

The concentration of chemicals in an inflammatory

It was noted that the patient's age placed him in an age group with a high incidence of low back pain and that in his job he must flex and lift frequently. The patient's description of increasing peripheralization (McKenzie . 1981) of pain and paraesthesia typically occurs in the presence of intervertebral disc pathology or prolapse. The peripheralizing of back and leg symptoms over time also suggested the problem was progressive and his condition was worsening. As this disorder has marked consequences if neglected. it would be unwise to ignore the signU1cance of progressively increasing radiating symptoms in the search for more obscure causes for his p robl em


It was likely that the back and leg symptoms were

related. but back and leg pain are not always con­ nected. Supportive evidence was needed. which could be obtained by increasing and decreasing the lumbar lordosis (flexing and extending the lumbar spine in sitting) to test the effect of spinal loading on the leg symptoms .


condition does not generally reduce with change of position or unloading or exercise. Therefore. if the symptoms are intermittent or influenced by position. they are unlikely to be inflammatory in origin. Similarly. repeated moveme nt or prolon ged loading will either have no effect or will increase rather than decrease the symptoms. However, if the symptoms result from internal derangement of a lumbar disc. repeated movements in one direction may increase displacement and cause an increase in pain. while movement in the opposite direction may decrease dis­ placement and cause a decrease in pain. In this case. the pain was constant and so it could have been chemical in origin or have arisen from con­ stant m echan ical deformation. such as might occur



internal disc derangement. The behaviour.

however, suggested the pain was not primarily chemical in nature. It is improbable that pain related to inllam­ mation would appear and ctisappear on change of pos­ ition. The behaviour did tend to support the hypothesis that the symptoms were likely to have arisen from increaSing and decreasing mechanical disc deform­

At the conclusion of the history, did the behaviour of the symptoms with movement tend to support or discount your hypothesis! Were there any factors (e.g. environmental, psychosocial, biomechanical) that you considered had contributed to the onset or deterioration of his disorder!

ation. The constant back pain was, therefore. most probably caused by an' internal disc derangement. which could increase or decrease. thus provoking in termittent pain in the leg according to the patient's position or movement. The reduction in leg pain on waU<ing a short dis­ tance may have been a consequence of the lumbar spine extension effect of walking. However. walking

• Clinicians' answer

longer distances may have caused prolonged com­

Pain can arise from either chemical or mechanical

pression loading of

causes (Wyke. 1980). Pain of chemical origin will


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posterior disc bulge . leadin g to

Perhaps the relief

n oted while



bend ing (i.e. in slight spinal Ilexion) was a result of

work. Th is involved frequ ent aod sustained spinal

reduced compression of the posterior displacement.

flexion. Despite the risks. the patient was reluctant to

Unloaded flexion d ec ompresses the disc but is unlil e ly

ce ase work.

to reduce or alter the location of displaced tissue. The reported difficulty getting out of bed in the morning was also consistent with a mechanical disc problem . Compressive forces on a nocturnally imbibed

• Clinical reasoning commentary

disc would. under these circumstances. increase back

Pattern recognition is typical of the clinical

pain and the patient is at increased risk of aggravation of

soning process of expert clinicians.

symptoms in the first few hours of the day. Interestingly.

in this response. Early in the clinical session. cues



is evidenced

it has been reported that recurrence of low back pain is

are reco gnized (e.g. area of the sy mptoms. age of

most W<ely in the first few hours of the day (McKenzie.

the patient) that relate to a familiar clinical pattern



Snook et al..


Differentiation between

syn dro me (e.g. peripheralization of pain possi­

ation. If pain location changes or its intenSity reduces

disc prolapse). c l in ic al experience with simi­ lar cl ini c al presentations is integral to t h is process.

\vi th repeated movement testing. then the pain cannot

However. it is still necessary that the diagnostic

chemical and mechanical causes should be aided by the use of repeated movements during the physical examin­

be chemical in nature. Sitting in


bly as a result of intervertebral

S i gnific ant previous

hypothesis be tested by further examination

truck elicited tingling a n d numbness in


increasing and de c re as in g the lumbar lordosis to

Jamie's right foot. Sitting in this position flattens or

determine the effect of lumbar posture on the

nexes the lumbar spine. The i ntermitte nt neurologic al

sympto ms) before it can be fully accep t e d and the

sy mptoms confIrmed intermitten t mechanical com­

problem well understood.

pression or irritation of the spinal nerve root was

Hypo theses are not limited to ju st the structural

occurring, prob ably as a result of lumbar Oexion. The

source of a pat ie nt s c om pl a i n t

fact that the tingling and numbness was not constant

As illustrated in the clinicians' second answer.





also suggested that the condition m ay have been


rapidly reversible. If root compression spontaneously

activity/participation restrictions (e . g

ceases, it is usually possible to identify the position that

lo n g dis t ances) pathobiological mechanisms (e.g.

causes the d ecompression. In this case, he described

chemical). factors contributing to the problem

central ization occurring in unloaded extension of the

(e.g. work environment). management and treat­


also fall into other categories i ncluding .

w a l k ing


spine (e.g. lying prone). This suggested a good o u t­

ment (e.g. 'extension principles of treatment'), and

come would likely be achievable with the use of exten­

prognosis (e.g.

sion p rinC ip l es of treatment.

achievable'). These hypotheses together guide the

The only obvious factor that may have contribu ted


goo d outcome would likely be

ongoing examination by


re aso ning process in

to the problem. and which may have predisposed the

which they are eventually either refined or rejected

pa tient to rec urrence. was enviro nmental. that is his

on the basis of the cl i n i cal findings obtained.