process approach in physical therapies · predisposing persons to recurrent somatic dysfunction and...

Prof. Eyal Lederman DO PhDProf. Eyal Lederman DO PhD

Process approach in

physical therapies

CPDO Ltd CPDO Ltd

www.cpdo.netwww.cpdo.net

[email protected]@cpdo.net

Process Approach

Co-create with the patient environments in which their

recovery can be optimised.

Look at the patient’s underline processes and match the

intervention according to these needs

Why do we need a new model?

Physical therapies: alignment to a structuralPhysical therapies: alignment to a structural--orthopaedic orthopaedic

modelmodel

Conceptual model for musculoskeletal health

A model for how the body fails

Structural observational and diagnostic procedures

Recovery is associated with structural modifications

Structural-physical treatment

Utopian view of the body

Optimum structure = optimum functionAlso

Optimum control = optimum function

Technotopia

Mechanical Mechanical ““hardwarehardware”” idealsideals

Control Control ““softwaresoftware”” idealsideals

“Asymmetry within the pelvic structures can lead to a cascade of postural compensations throughout the axial spine, predisposing persons to recurrent somatic dysfunction and decreased functionality”

Juhl J et al Prevalence of Frontal Plane Pelvic Postural Asymmetry Part 1. J. American Osteopathic Association 104(10):411-421 2004

Utopian view of the body

Postural appearance: socialPostural appearance: social--cultural constructs of healthcultural constructs of health

Pretty = healthy, good, resilient Pretty = healthy, good, resilient

Unsightly = unhealthy, bad, weak, injury proneUnsightly = unhealthy, bad, weak, injury prone

No association between structure, biomechanics

and LBP

Trunk asymmetry, thoracic kyphosis and lumbar

lordosis in teenagers and developing LBP in adulthood

(Poussa MS 2005)

Elevation of one shoulder, elevation of one hip, and

deviation of the spine from the midline of the body to

LBP & neck pain (Dieck GS, 1985)

Low muscle strength, low muscle endurance,

or reduced spinal mobility and erector spinea

pairs imbalances during extension

(Hamberg-van Reenen HH 2007 & Reeves PN

2006)

Lumbar lordosis (Norton BJ 2004).

Spinal scoliosis (Christensen ST 2008 syst. rev.)

Increased lumbar lordosis and sagittal pelvic tilt on back

pain during pregnancy (Franklin ME 1998)

Differences in regional lumbar spine angles or range of

motion (Mitchell T, 2008)

Pelvic obliquity and the lateral sacral

base angle pelvic asymmetry

(Fann AV 2002 & Levangie PK 1999)

Inflexibility of the lower extremities or leg length

discrepancy (Nadler SF 1998)

Hamstrings and psoas tightness (Hellsing, 1988)

Correcting foot mechanics have no

effect on preventing back pain (Sahar

T, et al, 2007)

Lederman E 2010 Fall

of the postural-

structural-

biomechanical model

in manual and

physical therapies:

exemplified by LBP.

CPDO online journal.

www.cpdo.net

Disparity between pathomechanics and LBP

No corrolation:

Facet degeneration (n=160)

Spina bifida,

Transitional lumbar vertebra,

Spondylolysis / spondylolisthesis

Modic changes

Kalichman L, et al Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976).

2008 Nov 1;33(23):2560-5.

van Tulder et al 1997, syst. review, Luoma, 2004; Brooks et al 2009

Kalichman L, et al. 2010 Changes in paraspinal muscles and their association with low back pain and spinal degeneration:

CT study. Eur Spine J. Jul;19(7):1136-44

Keller A, et al 2011 Are Modic changes prognostic for recovery in a cohort of patients with non-specific low back pain? Eur

Spine J. Aug 12

Postural-behavioural factors

Lack of association:

Prolonged: standing, bending, twisting Awkward postures (kneeling or

squatting) Sitting posture at work

Prolonged sitting at work / homeRecreational sports activities

(Hartvigsen et al 2000 syst. review; Chen et al 2009 syst. review; Bakker et al 2009 syst. review; Roffey et al 2010 syst. review; Wai

et al 2010, syst. review).

Bishop MD, et al 2011 Magnitude of spinal muscle damage is not statistically associated with exercise-induced low back pain intensity. Spine

J. Dec;11(12):1135-42.

Increased signal intensity

Disparity between symptoms and pathology

Disparity between symptoms and pathology

Time Time -- weeks.. months.. yearsweeks.. months.. years

PathologyPathology

SymptomsSymptoms

Carragee, E et al 2006 Does Minor Trauma Cause Serious Low Back Illness? Spine. 31(25):2942-2949

Videman T 2006 Determinants of the progression in lumbar degeneration: a 5-year follow-up study of adult male

monozygotic twins. Spine. Mar 15;31(6):671-8

Battié MC 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A study relating lifetime

exposures and magnetic resonance imaging findings in identical twins. Spine. 1995 Dec 15;20(24):2601-12

Number of MRI

abnormalities

PRR (95% CI) [adjusted for treatment and other confounders]

Any pain Disabling pain

0 1 1

1 0.8 (0.6-1.1) 0.9 (0.4-2.0)

2 0.9 (0.7-1.1) 0.9 (0.4-2.0)

3 0.9 (0.7-1.1) 0.9 (0.4-1.9)

4 0.8 (0.8-1.2) 1.8 (0.9-3.6)

McNee P, et al 2011 Predictors of long-term pain and disability in patients with low back pain investigated by magnetic

resonance imaging: a longitudinal study. BMC Musculoskelet Disord. Oct 14;12:234.

Anomalies examined: Disc herniation (protrusion, extrusion or sequestration)Nerve root deviation or compression Disc degeneration High intensity zonesN=240

Disparity between spinal pathologies & LBP

Disparity between spinal pathologies &

LBP

Karppinen J, et al 2001 Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. Spine. Apr 1;26(7):E149-5

Masui T, et al 2005 Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech. Apr;18(2):121-6.

Degree of disc displacement, nerve root enhancement or nerve compression not correlated with pain level or disabilityN=160

SherSher JSJS et al Abnormal findings on magnetic resonance images of asymptoet al Abnormal findings on magnetic resonance images of asymptomatic shoulders. matic shoulders. J Bone Joint J Bone Joint SurgSurg Am.Am. 1995 Jan;77(1):101995 Jan;77(1):10--5. 5.

In all age groups, 34% had partial or full rotator cuff tears

The frequency of full-thickness and partial-thickness tears

increased significantly with age:

60 yrs +, had 54% (28% full tear, 26% partial)

40-60 yrs, (4% full tear, 24% partial)

19-39 yrs, only 4% had a partial tear

Disparity between structure and symptoms: can be applied elsewheDisparity between structure and symptoms: can be applied elsewherere

Control is highly variable - not like a computer

Jacobs JV, Henry SM, Nagle KJ 2009. People with chronic low back pain exhibit decreased variability in the timing of their anticipatory postural adjustments. Behav Neurosci. Apr;123(2):455-8.Moseley GL, Hodges PW. 2006 Reduced variability of postural strategy prevents normalization of motor changes induced by back pain: a risk factor for chronic trouble? Behav Neurosci. Apr;120(2):474-6

2 individuals, 75 overlaid trials

Why not mechanical?

Biological dimension

1. Genetic factors2. Capable of repair and adaptation3. Contains reserves4. Non-linear behaviour (systems)5. We don’t know

Why spinal degeneration?Why spinal degeneration?

Progression of degenerative signs:

Genetic and shared environmental influences47% to 66%

Resistance training and occupational physical loading together2% to 10%

N=116 twins. Study over 5yrs.

Videman TDeterminants of the progression in lumbar degeneration: a 5-year follow-up study of adult male monozygotic twins. Spine. 2006 Mar 15;31(6):671-8Battié MC 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance imaging findings in identical twins. Spine. 1995 Dec 15;20(24):2601-12

1) MacGregor AJ, et al 2004 Structural, psychological, and genetic influences on low back and neck pain: a study of adult female twins. Arthritis Rheum. Apr 15;51(2):160-72) Battie MC et al 2007 Heritability of low back pain and the role of disc degeneration. Pain 131:272–280Valdes AM, et al 2005 Radiographic progression of lumbar spine disc degeneration is influenced by variation at inflammatory genes: a candidate SNP association study in the Chingford cohort. Spine;30:2445–51Holliday KL, McBeth J. 2011 Recent advances in the understanding of genetic susceptibility to chronic pain and somatic symptoms. Curr RheumatolRep. Dec;13(6):521-7.

Heritability for LBP 52-68%1 / 30% to

46%2

Neck pain 35-58%.

Why pain?

Mechanical systems in overloadingMechanical systems in overloading

Ran

geR

ange

ToleranceTolerance

DamageDamage

Progressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failure

ToleranceTolerance

Lederman E 2010 Fall of the postural-structural-biomechanical model in manual and

physical therapies: exemplified by LBP. CPDO online journal

Lederman E. 2011 The fall of the postural-structural-biomechanical model in manual and

physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. Apr;15(2):131-8.

Physiological Physiological rangerange

End rangeEnd range

End rangeEnd range

Potential Potential adaptive rangeadaptive range


Biological systems in overloading: acute option Biological systems in overloading: acute option -- repairrepair

InjuryInjuryInjuryInjuryInjuryInjuryInjuryInjury

RepairRepairRepairRepairRepairRepairRepairRepair





Biological systems in overloading: chronic option - adaptation

Physiological Physiological rangerange

End rangeEnd range

End rangeEnd range



OverloadingOverloadingOverloadingOverloadingOverloadingOverloadingOverloadingOverloadingRemodelled end Remodelled end rangerange

AdaptationAdaptationAdaptationAdaptationAdaptationAdaptationAdaptationAdaptation





No progressive failureK

Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. 2009 Pain in the lumbar, thoracic or cervical

regions: do age and gender matter? A population-based study of 34,902 Danish twins 20-71 years of

age. BMC Musculoskelet Disord. Apr 20;10:39.

Frequency of back and neck pain same at all ages (20-71yrs)Duration slightly longer in older age

Supraspinatous calcification: cure or calm?

Left

Right

A scan of my “uncured” but “calmed” supraspinatous calcification

Recovery depends on cure or/and calmRecovery depends on cure or/and calm

CureCalm

or/and

Repair Adaptation Homeostasis(e.g. Short term pain alleviation)

No evidence to suggest that we

should treat humans like a structure

out of alignment

What is the use of a profound knowledge of

anatomy? Does it help the treatment?

What is the purpose of a standing examination?

Is palpation useful to explain a condition?

What are the aims of manual techniques or

exercise?

ClinicallyClinically

Process Approach

An alternative

modelK

Process Approach

Co-create with the patient environments in which their

recovery can be optimised.

Identify the processes that underlie the patient’s

condition and match the intervention according to these

needs

Complex adaptive systemsThe number of elements is sufficiently large that conventional descriptions cease to assist in understanding the system

The elements interact dynamically. Interactions can be physical or involve the exchange of information.

Interactions are multi-directional. Any element in the system is affected by and affects several other systems.

The interactions are non-linear - small causes can have large results.

Any interaction can feed back onto itself directly or after a number of intervening stages, such feedback can vary in quality.

Systems are open - may be difficult or impossible to define system boundaries

Operate far from equilibrium conditions

All complex systems have a history, they evolve and their past is co-responsible for their present behaviour

Some elements in the system are autonomous responding only to what is available to it locally

CLBP as a processCLBP as a process

Too much to considerComplexity

Worse, better, chronic, recurrent etcSeveral possible outcomes

Is the pain new injury or sensitisation / inability to identify tissue

causing symptomsUncertainty

Condition is still there even during pain-free periodOutcome is only a particular point

within a continuum

Motor and behavioural responses associated with pain experience Inter-related processes

Sensitization + protective motor reorganizationMultiple systems, sub-events,

processes

Repair in local dimension, muscular reorganisation in neurological

dimension as well as psychological distressOccur in different dimensions

Pain associated with repair in acute changes to sensitization in chronicUnderlying mechanisms change

over time

Turning in bed is painful, but playing squash is OKNon-linear relationship between

input-output

Pain is not an indication of damageComplex relationships between

processes

Undefined time scale, can be recurrent, various duration. Switch on-off

without obvious causeContains a time dimension

Management and recovery: multidimensional Management and recovery: multidimensional

processesprocesses

Repair

Fluid flow

Length adaptation

Neuromuscular

PROCESSES

Nociceptive

Psychological/cognitive/

behavioural

Psycho-physiological

Psychological

Neural

Physical /

Local

tissue

DIMENSIONINTERVENTION

Pain / suffering

Repairor / and

Adaptation

Long term change in any process depends on..

� Intrinsic processes

� Time dependent

� Environment dependent

LBP: a multidimensional condition in many dimensionsLBP: a multidimensional condition in many dimensions

PROCESSES

Psychological

Neural

Physical /

Local

tissue

DIMENSION CLBP

??? Not associated with tissue damage

(except in acute)

Repair??

More likely in acute LBPFluid flow

Tissue shortening or ROM sensitization?Adaptation

Persistent sensitizationNociceptive

Motor reorganisation

Loss of movement variability

Neuromuscular

Higher centre mediated sensitization

Reduced pain tolerance


Pain / suffering

Fear avoidance

Catastrophizing

Psychological distress: depression,

anger, anxiety, hopelessness


behavioural

To be as they were before: full functionality

What the patient wants

Pain and ROM

Pain alleviation is multiPain alleviation is multi--dimensionaldimensionalKK

Assist tissue repair

Normalisation of motor

control

PROCESSES

Nociceptive inhibition

Reduce fear avoidance

and catastrophizingPsychological

Neural

Physical /

Local

tissue


Active movement (task specific / functional)

Dynamic movement (passive or active)

Dynamic movement (passive or active)

Support / reassurance / empathyRaise pain tolerance

Reduce sensitization

condition time-line

Support repair

Acute Subchronic Chronic

Tissue dimension

Neurological dimensionManaging pain: Treatment strategies / processes Managing pain: Treatment strategies / processes

change over timechange over timeKK

RepairAdaptation

Pain alleviation and desensitization

Obscure protective roleApparent protective role

ROM Recovery is also multiROM Recovery is also multi--dimensionaldimensionalKK

Length adaptation

Recover control of

active ROM

PROCESSES

Promote ROM

desensitization

Reduce fear avoidance

Reduce catastrophizing

Psychological

Neural

Physical /

Local

tissue


Task specific, working with task parameters

Passive or active stretching approaches? (may not be effective!)

External focus of attention, dynamic, active movement

Cognitive and behavioural reassurance

condition time-line

Support repair

Acute Subchronic Chronic

Tissue dimension

Neurological dimensionManaging ROM: Treatment strategies / processes Managing ROM: Treatment strategies / processes

change over timechange over timeKK

RepairAdaptation

ROM loss obscure protective roleROM loss apparent protective role

Psychological dimension

ROM desensitization

Alleviate fear of movement

Higher disability levels

Psychological distress

More social dysfunction

More social isolation

Receiving higher compensation

Work relations

Low job satisfaction

Low social support

Fear avoidance

Depression

Anxiety

Sexual & physical abuse

Psychological

Frequent heavy lifting (small

effect)Occupational

Initial high intensity pain

Specific LBP

Referred pain to LEX

Delay in treatment

Female > males

Previous history of LBP

Genetic factorsPhysiological-

biological

Long term sick leaveRisk factors

Risk factors for CLBPRisk factors for CLBP

Nikolai Bogduk. Psychology and low back pain. IJOM 9 (2006) 49-53

Occupational and Environmental Medicine 2005;62:851-860

Balagué F, et al 2012 Non-specific low back pain. Lancet. Feb 4;379(9814):482-91.

LBP lottery: Uncertainty of cause

Focusing on a single factor may be ineffective

The uncertainty of diagnosis

FacetFacet

DiscDisc

MuscleMuscle

1. Many spinal tissues share the same symptomatology

2. Sensitization spreads(Undamaged tissues will become sensitive to mechanical loading)

3. Physical examination is not tissue specific(Individual loading of tissue is highly unlikely)

LBP + LEXLBPChronicOver 8 wks

LBP + LEXLBPAcuteUp to 8 wks

Embracing uncertainty: presentation lead management (rather thanEmbracing uncertainty: presentation lead management (rather than tissue tissue

diagnosis)diagnosis)

Intervention as a processes

Intervention: environment reconstruction for changeIntervention: environment reconstruction for change

Repair

Fluid flow

Adaptation

Neuromuscular

PROCESSES

Nociceptive


behavioural


Psychological

Neural

Physical /

Local

tissue


Pain / suffering

Recovery in the tissue dimensionRecovery in the tissue dimension

Repair

Fluid flow

Adaptation

Neuromuscular

PROCESSES

Nociceptive


behavioural


Psychological

Neural

Physical /

Local

tissue


Pain / suffering

Fibroblast

Myocyte

Change in physical environment

MechanotransductionMechanotransduction

A

B

C

D

A. Normal ligament

B. Ligament after 6 weeks

of immobilisation

C. Effects of immobilisation

D. Effects of 6 weeks of

passive movement

Mechanotransduction and adaptationMechanotransduction and adaptation

Effects on tensile strengthEffects on tensile strength

Trans-synovial pump

Alteration in intra-

articular pressure

Increased blood flow

around the joint

Increase lymphatic flow &

drainage around the joint

Fluid flow

Movement

High(in functional rehabilitation)

HighHighHighLow stress

active

movement

LowLowLowLowCranial

LowLowLow to mediumLowTraction

Low

Low

Low

Low

Medium to high

Medium to high

Perfect

Resemblance to

real movement

HighHighHighHuman

movement

HighHighHighArticulation

low

Low

Low to medium

High (if in compression)

High

Adequate stress RepetitiveDynamicTechnique

HighHighHarmonic

HighHighMassage ST

LowLowHVT

LowLowFunctional

LowLowStretch

Matching techniques to physiology of repair

Recovery in the neurological dimensionRecovery in the neurological dimension

Repair

Fluid flow

Adaptation

Neuromuscular

PROCESSES

Nociceptive


behavioural


Psychological

Neural

Physical /

Local

tissue


Pain / suffering

A functional approach to functionality

Functional movement - the unique movement repertoire of an individual.

Functional rehabilitation - the process of helping a person recover their

movement capacity by using their own movement repertoire (whenever

possible).

Extra-functional – a movement pattern outside the individual’s movement

repertoire

Lederman E. 2010 Neuromuscular Rehabilitation in manual and

physical therapies. Elsevier

Competition in adaptation: intervention vs. condition

processes

Pain Pain Pain Pain sensitizationsensitizationsensitizationsensitization

ororororROMROMROMROM

Treatment

Transforming habitual cognitive and behavioural patterns is essential for success

Repetition

Cognition

Specificity

FeedbackActive

Conditions for learning, adaptation and recovery

Functional approach

Shared skillsShared skills Unique skillsUnique skills

Functional repertoireFunctional repertoire

Increase stair Increase stair

climbingclimbing

+ 2 stairs at a + 2 stairs at a

timetimeIncrease Increase

walking + walking +

walking on walking on

heels or toesheels or toesSkipping Skipping

over an over an

obstacleobstacle

Tapping Tapping

with heel with heel

or toesor toes Gentle Gentle

running on running on

treadmilltreadmill

Lederman E. 2010 Neuromuscular Rehabilitation in manual and physLederman E. 2010 Neuromuscular Rehabilitation in manual and physical therapies. Elsevierical therapies. Elsevier

YesHighHighHighHighFunctional

rehabilitation

noLowLowLow -HighLowMET

noLowLownoLowHVT

LowLowHighHighHighCore stability

noLowLownoLowTraction

no

low

no

no

no

Perfect

Similarity

To real

movement

Low

Low

Low

Low

Low

High

Repetition

LownoLowStretch

no

no

no

no

High

Active FeedbackCognitionTechnique

HighHighHuman

movement

LowLowMassage ST

LowLowArticulation

LowLowFunctional

LowLowCranial

Matching approach to motor control recovery

Recovery in the psychological dimensionRecovery in the psychological dimension

Repair

Fluid flow

Adaptation

Neuromuscular

PROCESSES

Nociceptive


behavioural


Psychological

Neural

Physical /

Local

tissue


Pain / suffering

Aims in the psychological dimension

To explore and understand the To explore and understand the psychological processes that can assist or psychological processes that can assist or impede recoveryimpede recovery

Therapeutic encounter

TreatmentBackground Background

HistoryHistory

BeliefsBeliefs

AttitudesAttitudes

Etc.Etc.

Background

History

Beliefs

Attitudes

Etc.Practitioner Patient

Relationship

Physical/contractual

boundaries

Fox S 2008 Relating to clients. Jessica Kingsley Publishing. London

Working with cognition and behaviour

CognitionsFear

Anxiety

catastrophising

BehaviourWithdrawal from activities

Activity cycling

Illness behaviour

Behavioural spheres

Therapeutic focus

Therapeutic focus

Contextual affects / factors

Treatment outcomes are highly dependent on contextual affects

The closer you look the

less you’ll see..

Behavioural spheres and LBP management

TaskTask--behaviourbehaviour

PsychosocialPsychosocial--behaviourbehaviour

OrganisationalOrganisational--behaviourbehaviour

Lederman E. 2010 Neuromuscular Rehabilitation in manual and

physical therapies. Elsevier

Treatment as

optimisation

TreatmentTreatment

Daily activityDaily activity

General / specific exerciseGeneral / specific exercise

Injury / illnessInjury / illness

BehaviourBehaviour

Patient dependant

Therapist dependant

Success of treatment rely on:

• Patient’s repair and adaptation status

• The ability of therapist to identify the underlying

process

• The ability to match the ideal management / care

/treatment to facilitate a change in these processes

The down sideThe down sideKK..

A process approach ultimately relays on research to inform

us about the condition and underlying processes:

1. May be wrong.. (e.g. the core model – loss of core

stability = back pain

2. May be insufficient research or knowledge (e.g. why

some individuals can have profound musculoskeletal

damage but no pain, and why others become

symptomatic

3. Research is about the average, individuals are individual

Differences between structural and process approaches

Accepts variability and individualityAccurate / precise

Processes ruleAnatomy rules

Towards co-created managementTherapist dominates the treatment

Uncertainty is OKCertainty

Condition is understood through its underlying processes Condition is understood by structural factors

Based on bio-psycho-social sciencesBased on biomechanical models (many now obsolete)

Diagnosis embraces uncertainty and is informed by processesDiagnosis is dominated by structural examinations and

considerations

Broad multidimensional assessment (difficult to define)Examination is mostly structural

Patient needs / processes dictate management Technique led – often a series of manual events

Condition occurs in many dimensionsOften in single biomechanical dimension

Treatment aims to facilitate processes associated with

recovery, such as repair / adaptation

Create an environment for change

Treatment aim to correct, improve or enhance physical

structure

(many techniques have no effect on what they try to achieve)

Techniques don’t exist. Manual / physical events are seen as

a vehicle to deliver signals / stimulation for change

Part of the co-created environment

Techniques are seen as mechanical forces that can alter and

correct structure

Open, creative and continuously changing according to needsProtocol based

Process modelStructural-orthopaedic model

Find out more:

Books:The science and practice of manual therapy.

Neuromuscular rehabilitation in manual and physical therapies

Workshops:See: www.cpdo.net

Contact: [email protected]

process approach in physical therapies · predisposing persons to recurrent somatic dysfunction and...

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