Process approach in physical therapies

Prof. Eyal Lederman DO PhD

CPDO Ltd www.cpdo.net cpd@cpdo.net

Process Approach
Co-create with the patient environments in which their recovery can be optimised.

Look at the patients underline processes and match the intervention according to these needs

Why do we need a new model?

Physical therapies: alignment to a structural-orthopaedic model

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 function Also Optimum control = optimum function

Technotopia

Mechanical hardware ideals

Control software ideals

Utopian view of the body

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):411421 2004

Postural appearance: social-cultural constructs of health

Pretty = healthy, good, resilient Unsightly = 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 posturalstructuralbiomechanical 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 / home Recreational 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).

Disparity between symptoms and pathology

Increased signal intensity

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.

Disparity between symptoms and pathology

Symptoms

Pathology

Time - weeks.. months.. years

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 Batti 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

Disparity between spinal pathologies & LBP

Number of MRI abnormalities 0 1 2 3 4

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

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

Any pain 1 0.8 (0.6-1.1) 0.9 (0.7-1.1) 0.9 (0.7-1.1) 0.8 (0.8-1.2)

Disabling pain 1 0.9 (0.4-2.0) 0.9 (0.4-2.0) 0.9 (0.4-1.9) 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.

Disparity between spinal pathologies & LBP

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

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.

Disparity between structure and symptoms: can be applied elsewhere

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

Sher JS et al Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5. asymptomatic Jan;77(1):10-

Control is highly variable - not like a computer

2 individuals, 75 overlaid trials

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

Why not mechanical?

Biological dimension
1. Genetic factors 2. Capable of repair and adaptation 3. Contains reserves 4. Non-linear behaviour (systems) 5. We dont know

Why spinal degeneration?

Progression of degenerative signs:

Genetic and shared environmental influences 47% to 66% Resistance training and occupational physical loading together 2% 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):671-8 Batti 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

Why pain?

Heritability for LBP 52-68%1 / 30% to 46%2 Neck pain 35-58%.

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):160-7 2) Battie MC et al 2007 Heritability of low back pain and the role of disc degeneration. Pain 131:272280 Valdes 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;30:244551 Holliday KL, McBeth J. 2011 Recent advances in the understanding of genetic susceptibility to chronic pain and somatic symptoms. Curr Rheumatol Rep. Dec;13(6):521-7.

Mechanical systems in overloading

Damage

Tolerance

Range

Progressive or catastrophic failure

Tolerance

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.

Biological systems in overloading: acute option - repair

Potential adaptive range End range

Injury

Physiological range

Repair

End range

Potential adaptive range

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.

Biological systems in overloading: chronic option - adaptation

Potential adaptive range End range

Overloading

Remodelled end range

Adaptation
Physiological range

End range Potential adaptive range

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.

No progressive failure

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

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.

Supraspinatous calcification: cure or calm?

Left

Right

A scan of my uncured but calmed supraspinatous calcification

Recovery depends on cure or/and calm

or/and

Cure

Calm

Repair

Adaptation

(e.g. Short term pain alleviation)

Homeostasis

No evidence to suggest that we should treat humans like a structure out of alignment

Clinically
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?

Process Approach
An model alternative

Process Approach
Co-create with the patient environments in which their recovery can be optimised. Identify the processes that underlie the patients condition and match the intervention according to these needs

Complex adaptive systems

The 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 process
Contains a time dimension Multiple systems, sub-events, processes Inter-related processes Occur in different dimensions Complex relationships between processes Non-linear relationship between input-output Underlying mechanisms change over time Outcome is only a particular point within a continuum Several possible outcomes Uncertainty Complexity Undefined time scale, can be recurrent, various duration. Switch on-off without obvious cause Sensitization + protective motor reorganization Motor and behavioural responses associated with pain experience Repair in local dimension, muscular reorganisation in neurological dimension as well as psychological distress Pain is not an indication of damage Turning in bed is painful, but playing squash is OK Pain associated with repair in acute changes to sensitization in chronic Condition is still there even during pain-free period Worse, better, chronic, recurrent etc Is the pain new injury or sensitisation / inability to identify tissue causing symptoms Too much to consider

Management and recovery: multidimensional processes

INTERVENTION DIMENSION PROCESSES

Psychological

Psychological/cognitive/ behavioural Psycho-physiological Pain / suffering

Neural

Neuromuscular

Nociceptive

Physical / Local tissue

Repair Fluid flow Length adaptation

Long term change in any process depends on..

Repair
or / and

Adaptation

Intrinsic processes Time dependent Environment dependent

LBP: a multidimensional condition in many dimensions

DIMENSION

PROCESSES

CLBP
Fear avoidance Catastrophizing Psychological distress: depression, anger, anxiety, hopelessness Higher centre mediated sensitization Reduced pain tolerance

Psychological

Psychological/cognitive/ behavioural

Psycho-physiological Pain / suffering

Neural

Neuromuscular

Motor reorganisation Loss of movement variability Persistent sensitization

Nociceptive

Physical / Local tissue

Repair?? Fluid flow

??? Not associated with tissue damage (except in acute) More likely in acute LBP

Adaptation

Tissue shortening or ROM sensitization?

What the patient wants

To be as they were before: full functionality

Pain and ROM

Pain alleviation is multi-dimensional

INTERVENTION

DIMENSION

PROCESSES

Psychological Support / reassurance / empathy

Reduce fear avoidance and catastrophizing Raise pain tolerance Reduce sensitization

Active movement (task specific / functional) Dynamic movement (passive or active)

Neural

Normalisation of motor control Nociceptive inhibition

Physical / Dynamic movement (passive or active) Local tissue

Assist tissue repair

Managing pain: Treatment strategies / processes change over time

Neurological dimension Tissue dimension

Pain alleviation and desensitization Support repair

condition time-line

Acute

Subchronic Adaptation

Chronic

Repair

Apparent protective role

Obscure protective role

ROM Recovery is also multi-dimensional

INTERVENTION

DIMENSION

PROCESSES

Psychological Cognitive and behavioural reassurance

Reduce fear avoidance

Reduce catastrophizing

Task specific, working with task parameters External focus of attention, dynamic, active movement

Neural

Recover control of active ROM Promote ROM desensitization

Physical / Passive or active stretching approaches? (may not be effective!) Local tissue
Length adaptation

Managing ROM: Treatment strategies / processes change over time

Psychological dimension Neurological dimension Tissue dimension

Alleviate fear of movement

ROM desensitization Support repair

condition time-line

Acute

Subchronic Adaptation

Chronic

Repair

ROM loss apparent protective role

ROM loss obscure protective role

Risk factors for CLBP

Risk factors
Physiologicalbiological Occupational
Previous history of LBP Genetic factors

Long term sick leave

Initial high intensity pain Specific LBP Referred pain to LEX Delay in treatment Female > males

Frequent heavy lifting (small effect)

Psychological

Low job satisfaction Low social support Fear avoidance Depression Anxiety Sexual & physical abuse

Higher disability levels Psychological distress More social dysfunction More social isolation Receiving higher compensation Work relations

Nikolai Bogduk. Psychology and low back pain. IJOM 9 (2006) 49-53 Occupational and Environmental Medicine 2005;62:851-860 Balagu 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

1. Many spinal tissues share the same symptomatology

Disc Facet Muscle

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)

Embracing uncertainty: presentation lead management (rather than tissue diagnosis)

Acute
Up to 8 wks

LBP

LBP + LEX

Chronic
Over 8 wks

LBP

LBP + LEX

Intervention as a processes

Intervention: environment reconstruction for change

INTERVENTION

DIMENSION

PROCESSES

Psychological

Psychological/cognitive/ behavioural Psycho-physiological Pain / suffering

Neural

Neuromuscular

Nociceptive

Physical / Local tissue

Repair Fluid flow Adaptation

Recovery in the tissue dimension

INTERVENTION

DIMENSION

PROCESSES

Psychological

Psychological/cognitive/ behavioural Psycho-physiological Pain / suffering

Neural

Neuromuscular

Nociceptive

Physical / Local tissue

Repair Fluid flow Adaptation

Mechanotransduction

Change in physical environment

Myocyte Fibroblast

Mechanotransduction and adaptation

A C

A. Normal ligament B. Ligament after 6 weeks of immobilisation

C. Effects of immobilisation D. Effects of 6 weeks of passive movement

Effects on tensile strength

Trans-synovial pump
Movement

Increased blood flow around the joint

Alteration in intraarticular pressure

Increase lymphatic flow & drainage around the joint

Fluid flow

Matching techniques to physiology of repair

Technique Human movement Low stress active movement Harmonic Articulation Massage ST Stretch Traction Cranial Functional HVT Dynamic High Adequate stress High Repetitive High Resemblance to real movement Perfect

High

High

High

High
(in functional rehabilitation)

High High High Low Low Low Low Low

High High High (if in compression) Low to medium Low to medium Low Low low

High High High Low Low Low Low Low

Medium to high Medium to high Low Low Low Low Low Low

Recovery in the neurological dimension

INTERVENTION

DIMENSION

PROCESSES

Psychological

Psychological/cognitive/ behavioural Psycho-physiological Pain / suffering

Neural

Neuromuscular

Nociceptive

Physical / Local tissue

Repair Fluid flow Adaptation

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 individuals movement repertoire

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

Competition in adaptation: intervention vs. condition processes

Treatment Pain sensitization or ROM

Transforming habitual cognitive and behavioural patterns is essential for success

Conditions for learning, adaptation and recovery

Cognition Active Feedback

Repetition

Specificity

Functional approach

Functional repertoire

Shared skills

Unique skills

Increase stair climbing + 2 stairs at a time

Tapping with heel or toes

Increase walking + walking on heels or toes

Gentle running on treadmill

Skipping over an obstacle

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

Matching approach to motor control recovery

Technique Cognition Active Feedback Repetition Similarity To real movement Perfect Yes Low no no no no no low no no

Human movement Functional rehabilitation Core stability HVT MET Massage ST Cranial Functional Articulation Stretch Traction

High High High Low Low Low Low Low Low Low Low

High High High no Low -High no no no no no no

High High High Low Low Low Low Low Low Low Low

High High Low Low Low Low Low Low Low Low Low

Recovery in the psychological dimension

INTERVENTION

DIMENSION

PROCESSES

Psychological

Psychological/cognitive/ behavioural Psycho-physiological Pain / suffering

Neural

Neuromuscular

Nociceptive

Physical / Local tissue

Repair Fluid flow Adaptation

Aims in the psychological dimension

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

Therapeutic encounter

Relationship

Treatment Background History Beliefs Attitudes Practitioner Etc.

Patient

Background History Beliefs Attitudes Etc.

Physical/contractual boundaries
Fox S 2008 Relating to clients. Jessica Kingsley Publishing. London

Working with cognition and behaviour

Therapeutic focus

Cognitions
Fear Anxiety catastrophising

Behaviour Therapeutic focus

Withdrawal from activities Activity cycling Illness behaviour Behavioural spheres

Contextual affects / factors

Treatment outcomes are highly dependent on contextual affects

The closer you look the less youll see..

Behavioural spheres and LBP management

Task-behaviour

Psychosocial-behaviour Organisational-behaviour

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

Treatment as optimisation

Daily activity

Injury / illness Behaviour Treatment

General / specific exercise

er ap is td Pa ep tie en nt da de nt pe nd an t

Th

Success of treatment rely on:

Patients 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 side .

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

Structural-orthopaedic model
Condition is understood by structural factors Often in single biomechanical dimension Based on biomechanical models (many now obsolete) Examination is mostly structural Diagnosis is dominated by structural examinations and considerations Treatment aim to correct, improve or enhance physical structure (many techniques have no effect on what they try to achieve) Technique led often a series of manual events Techniques are seen as mechanical forces that can alter and correct structure Therapist dominates the treatment Protocol based Accurate / precise Anatomy rules Certainty

Process model
Condition is understood through its underlying processes Condition occurs in many dimensions Based on bio-psycho-social sciences Broad multidimensional assessment (difficult to define) Diagnosis embraces uncertainty and is informed by processes Treatment aims to facilitate processes associated with recovery, such as repair / adaptation Create an environment for change Patient needs / processes dictate management Techniques dont exist. Manual / physical events are seen as a vehicle to deliver signals / stimulation for change Part of the co-created environment Towards co-created management Open, creative and continuously changing according to needs Accepts variability and individuality Processes rule Uncertainty is OK

Find out more: Books:

The science and practice of manual therapy. Neuromuscular rehabilitation in manual and physical therapies

Workshops:
See: www.cpdo.net Contact: cpd@cpdo.net