THE HUMAN EXTREMITIES MECHANICAl DIAGNOSIS AND THERAPY BY ROBIN MCKENZIE AND STEPHEN MAY The ab ility to treat musculoskeletal d isorde rs affecting the soft tissues and joints of the body is a relatively modem concept. In the past, pain, stiffness and injury were sim ply tolerated until the body adapted or broke down completely. Rep e titive Strain
Injury, 'housemaid's knee', tennis elbow and general physical dysfunction were accept of life's ageing process. However, improved social structure and treatment
ed as part
for these conditions mean that people expect to be able to regain good health, and want instant remedies for their pain. Numerous health care providers
-
family physicians, phYSiotherapists, chiropractors,
acupuncturists, naturopaths and osteopaths, among others - treat the painful symp toms of musculoskeletal conditions. These practitioners are so m etime s loath to admit defeat when the patient does not
respond
to traditional treatment. Patients put their
clinician in c harge of curing their condition and expect them to "do something". Often the patient is the first to give up, resigned to the belief that they cannot regain their physical health. The authors draw u p on current published scientific evidence which overwhelmingly identifies controlled movement and exercise as the most effective means of alleviating
pain and restoring function in patients with common musculoskeletal disorders. This latest text by Robin McKenzie and co-author Stephen May, allows the clinician
to provi d e the same self-treatment philosophy and management strategies first
described in McKenzie's text The Lumbar Spine, Mechanical Diagnosis and Therapy. These rarely discussed concepts are presented in straightforward language and are supported with over 100 photographs and illustrations. Other books by Robin McKenzie include Treat Your Own Back, Treat Your Own Neck,
The Lumbar Spine: Mechanical Diagnosis and Therapy, and The Cervical and Thoracic Spine: Mechanical DiagnOSiS and Therapy.
ISBN
0-9583647-0-2
9 780958 364706
.,
.".,..
The Human Extremities: Mechanical Diagnosis and Therapy
Ro bin McKenzie CNZM, OBE, FCSP
(Hon), FNZSP (Hon), Dip MT
Stephen May MA, MCSP, Dip MDT, MSc
Spinal Publications New Zealand Ltd
The Human Extremities Mechanical Diagnosis and Therapy First published in August 2000 by Spinal Publications New Zealand Ltd
PO Box 93, Waikanae, Wellington, New Zealand Fax 64 4 293-2897 Email:
[email protected] © Robin McKenzie 2000 All rights reserved. No part of this publication may be reproduced, stored in a retneval system, or transmitted in any form or by any means,
electronic, mechanical, including photocopying, recording or otherwise, without the prior written permission of the copyright holder. ISBN 0-9583647-0-2
Design by Next Communications Edited by Jan McKenzie and Writers' Ink Photography by Stedman Photographics Printed by Astra Print, Wellington, New Zealand
'r '
Dedication To my dear wife Joy:
ivl
Acknowledgments
I wo u l d like to acknowledge the very great contribution made by my friend and colleague Stephen May, MA, MCSp, Dip MDT, MSc, without whose assistance this book would ne ve r have been published Mr May has created order out of chaos and provided this text with
a
credibility that I hope will help change the mode of physiotherapy management of musculoskeletal disorders worlclwide. I would also like to thank
my daughter, Jan, who organised and
coordinated the various specialists required to successfully complete a project such as this. I thank her for her patience and dedication.
I must also acknowledge the assistance of the many faculty members of the McKenzie I n s t i tu te International for their helpful
c o m m e n ts
and criticism of the original text. Robin McKenzie
For their helpful suggestions and comments concerning grammar and contents, I must thank Kenneth May and Julie Shepherd.
Stephen May
Iv
About the Authors
Robin McKenzie was born in Auckland, New Zealand, in 1931 and g radu ated from the New Zeal and School of Physiother apy in 1952. He commenced priv ate practice in vVellington New Zeal an d in 1953, ,
,
specialising in the d ia gn osi s and treatment of spi nal diso rde r s .
During the 1960s, Robin M cK enzi e developed new conce pts of diagnosis and t r eatment derived from
a
system atic analysis of patients
with both acute and chronic back problems This system is now .
p r actise d g lob a lly by sp eci a lists in physiothe r apy, medicine and chiropractic
.
The success o[ the McKenzie concepts of dia gn osis and trea tme nt [or spinal problems has attracted interest from researchers worldwide.
The imp or tance of the di agn ostic system is now reco gn i sed and the extenl of the therapeutic e ffi cacy of the McKenzie method is su bj ect to ongO ing i nv estiga ti o n
.
Robin Mc Ke n z ie is an Honorary Life Member of the Ameri c an Phy sical Therapy As socia t i o n 'in recogn i tion of d Istingui s hed and meritorious service to the art and sci ence of physica l therapy and to the welfare
of mankind'. He is a m ember of the I ntern a tion al Society for the St u dy of the Lumbar Spine, a F el low of the American Back SOC iety
,
an H ono r ary Fellow of the New Zealand S ocie ty of Physiotherapists,
an Honorary L i fe Member of the N ew Ze ala nd M a nipu l a ti ve Therapists Associa ti o n and an Hon o rary Fellow of the Chartered ,
SOCiety of P hys iothe r apis ts in the U nited Kingdom. In the 1990 Queen's Birthday Honours, he was made an Officer of the Most
Excellent Order of the British Empire
In 1993 he received an
H o nor a ry Doctorate from the Russian Academy of Medical Sci ence s. In the 2000 New Ye ar s Honours List, Her M aj est y the Queen '
ap poin ted Robin Mc Kenz ie as a Co mp ani o n of the New Zealand Order of Merit. Robin McKenzie has au th ored four books
Treat Your Own Bach;
Treat YOL!r Own Neck; The Lumbar Spine: Mechanica l Diagnosis and Therapy; and The Cervical a nd Thoracic Spine: Mechanical Diagnosis and Therapy. With the p ub l ic a ti on of The Human Extremities. Mechanical Diagnosis and Therapy, Ro b in McKenzie, in collaboration
\vith Stephen May, describes the application of his methods for the management of musculoskeletal disorders in general As with his
publications dealing with spine-related problems, the emphasis in this text is directed at providing self-treatment strategies for pain and disability among the general population Stephen May was born in Kent, England, in 1958. He did his physiotherapy training in Leeds and graduated in 1990. Since
qualifying as a physiotherapist, Stephen has worked in the National Health Service in England. For the last eight years thIs has been in Primary Care.
Early on he developed a passionate interest in musculoskeletal physiotherapy which ensured he was a keen consumer of the research evidence. In 1995 Stephen successfully completed the McKenzie Diploma programme and in 1998 an MSc in Health Services Research and Technology Assessment. Stephen believes strongly that practice must be shaped by the evidence and that self-management concepts are the future of ph ySiothe rapy.
IVii
Contents
Introduction CHAPTER ONE
.................. 1
Muscul oskeletal Problems
.............. ... .... 7
Introduction
.............. 7
Prevalence
.............. .... 7
Health care
..................... ...................... ..
The site of the problems
........ ..... 10
..................................... 12
Natural history and clinical course
.
............. 14
Systematic reviews of commonly used treatments The problem of diagnosis
..........
.............. .... 16
.... 18
.
Conclusions
CHAPTER TWO
......... 20
Soft Tissue Properties
........... 21
Introduction
....... ......... ................. .. 21
Tissue injury
... 21
Recovery following trauma Inflammation
..... 2 2
Tissue repair Remodelling
21
. .
...... . . . .
. . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . .
. . . . . .
......... .. 22
. . . . . . . . . . .
.
.
.
.
.
Failure to remodel repair tissue
. . .
.
Degenerated tissue in which healing is suspended
23
. 26 . .
... 27
The effects of stress deprivation and exercise on connective tissue
.....................
. ... 28
.
Factors restricting a normal return to [unction
.30
Cumulative postural stresses on musculoskeletal tissue
.... 32
Contractile tissue loading Clinical im plications
...............................
. . . . . .
32
. . .
37
35
.
Sir Astley Cooper's engravings
CHAPTER THREE
Pain
.
Introduction Pain and nociception
59 59
. .
... 59
Sources of pain
. .
Activation of nociceptors
..
. . . . .
61
......
.60
Differentiating between chemical and mechanical pain
.63
. . . . . . . . . . . . . . . .
Constant pain - chemical cause (Constant Chemical Irritation)
......... ............
..63
Cause and onset
63
Behaviour of pain
. . . .
64
Key factors in the identification of pain of an inj1ammatory nature . . . . ..... . " ...................................... 66 .
.
viii
I Stage and status of disorder
....66
Constant pain - mechanical cause (Constant Tissue .. ........... .67
De fo rmat i on) Cause and onset
.
Behaviour of pain
. . . . . .
.
. . . . . . .
. . . . ......
.
..... ....... 67
........... ...... 68
Key factors in identifying constant pain of mechanical origin
69
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intennittent pain - mechanical cause (Intennittent Tissue Deformation)
.. .
.
.
.
.
. . .
.
. .
.
.. .... . . .
.
.
. . . . .
.
. . . . . . .
. . .. .
.
. . .
. .. . 69 .69
Behaviour of pain -
.
normal tissue
Abnormal tissue
............................
................................................
...................................................
.
70 70
.... 71 72
..
. . . . . . . . . . . .
. . .
.. . .
.
.
.
.
. ...... .......... . 73
. .
. .
. . . .. .. .. .
.
.
.
.
.
.
.
. . 75 . .
. . .. 79 . .
Introduction
.
...............
.
.
.
.
............ .. .
. ... .
............
.
The postural synd ro me
...
The d ysfu n cti o n s yndrom e
..
.
. ....... 7 9
....
... 79 . . 79
The role of diagnosis in musculoskeletal problems
. .
... .
.
. ......... 81
. ......... ... ........
.82 ..... 82
. ........
83
. .................. ..
The deran ge men t syndrome Non-mechanical conditions
......
.... 85
Acute pain
........... 85
Chronic pain
.
Conclusion
History
..
. . . . .
. 86 .
.. .................
Int ro d uc tion
...... 89
Aims of history-taking
...
The interview
........ . ...... .
90
............ 91
Age
. .
Work and leisure activities Functlonal disability
.
.... 77
Mechanical Diagnosis
Making a non-specific d i agnosi s
.
...............
the state of the tissues
The medical model
CHAPTER FIVE
.
..... 74 .
Chronic pain states
CHAPTER FOUR
.
.
.
Derangement
-
.
.
Failure to remodel repair tissue
Conclusion
.
of mechanical
Key factors in identifying intermittent pa i n origin
. .
...............
Cause and onset
Postural pains
.
...........
Where is the present pain?
. 91 .
.... 91 .
...... 91 92
. " .................... " .... "" 92
How long has the pain been present?
.
Did the pain commence following injury!
"
"" . .." .." ... 94 "
. ..
Did the pain commence for no apparent reason?
.. . .
. . .
.
.
.
. . .
Is the p rob l em improving, worsening or unchanging! Is the pain constant?
.
. . . "",, ...... """"".,,....... . .
. .
. 97
.
Is the pain intennittent?
" .. . .
. . . .
... .
.
95
. 96
, ,"" "
" .
98
What activities produce or worsen the pain! What activities stop or reduce the pain? Does it remain worse
" ........""........." ... "",,.......
or better afterwards?
."."". 98
Does continued use of the affected area increase, decrease or have no effect on your pain!
... "....,," .................. ".,,"" 99 . .
Do Y0Lt have pain if the limb or part is relaxed at rest?
.
. . .
" 100
Can you find a position that stops your pain? . . .. " ........""",,.. . ................. 100
If so, please describe
.
.
.
Do you get better or worse as the day progresses? Is it a pro b l e m at night?
."".........." .....".. "..........."" ....." 100
. . .
Have you had any previous treatment for this episode? Have YOll ever had this problem before?
.
. .
.
.
... . .
.
. . .. ... . . .
. . . . . .
. . . . . . .
. .
.
. . . . . .
. ... . 101 .
.
. . . . .
.
. .
.
.
."....... 102
. . .. ... . .
.
.
. . .
.. ... .
Have you been x-rayed for this problem?
.
102
.. 103
. . . . . . . . . .
Conclusion
CHAPTER SIX
.
. .." .......... . ... 10 1
Are you taking any medication for this problem? Is your general health good or poor?
. 10 1
......""". . ,, ..."" 10 1
"
What treatment was given for that problem? Do you get back or neck pain?
. . . .
........ . .. 103
Physical Examination .......
Introduction
.............. . ..... 105 .
. . . "
Aims of physical examination
...
. .
... .
. ... lOS
.
...................... .
.
.
.
.. . .. . .
..... ......
Observmion
. .
. . .
....
. 10 6 107
Mechanical evaluation
.107
Role of palpation
. 107 ..... 108
Use of the assessment form
Active movement
.................................... 109
Active movement summary
....... "" .... ....."" ....... " "
... " ... "......... ...........
Passive movement
.
. . . .
Resisted tests sllmmary
.. .
III
" ......................" ...,," 112
Passive movement with overpressure
" ..... " ..... "" 114
Passive movement with overpressure summary . . . . . . .
...........
.. "" .. " ................. " "... "" .. "., 112
Passive movement summmy
Resisted tests
..... .. 111
.. " ..... . ......... ".""",, ............... 1 14
.
.
.
. . .
.. .
Repeated movement or loading
.
. . . . . .
.. .
. . . . .
. ..
. . .
.
. . . .
"...." ........... 11S
. . . " . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
lIS
xl Repeated movement in the postural syndrome
. .. . . . ".". 118
.
.
Repeated movement in the dysfunction syndrome
. .
... . . .... . .. 118 .
Repeated movement in the derangement s y n d rom e SummCllY
.............. ..............
Neurological examination
.
. . . . .
............ 11 8
119
.
. . . . . .
. . . . . .
.. .
. . .
.
.
.
...
.
.. . . .
.
.
..119
.
Co n clus i ons
...... 120
I n c o n c lu siv e res u l ts
CHAPTER SEVEN
.121
Assessment of Symptomatic and lVIechanical Presentations and Responses Introduction
. . . . . . . . .
. . . . . . . . . . . . . .
. . . . . . .
..
. . . . .
.
.
.
.
.
.
.
.
.
.... 123
Mechanical presentation and its assessment
. . .
Assessment of the symptomatic presentation
Chronic pa in
CHAPTER EIGHT
. . .
.. . ..... .. .............
.
.
.
.
.
.
.
.
..... 133 .
. . . . .
.
.
.
.
.
1 33
............. ..... l33
Education com p onen t of management me
chan i c a l therapy co mpo n en t
..... 137
Compliance or therapeutic alliance:> To treat or not to treat:>
.
.
.
.
.
.
.
Condition improving
.
. .
.
.
. 138
.
.
139
.... 140
Conditi on unchanging
141
Co nditio n worsening Conclusions
Management and Sel f-Treatment
.
.
.
142
.
.
.
144
..... . ....... 14'5
lntroduction
.... l45
Normal tissues, abnormal stresses - Postural Syndrome
. . .
EdLtwtion towards self-management
.
Self-treatment procedures required Acut e p resentati o ns
.
.
.
. .
.
. . .
. . . .. .
.
. . . .
Sub-acute presentations
. . .. .
.
. .
".
Post-trauma - tissue h ea li ng
.
. .. .
.
.
.
.
""".,,
.
.
147
.. 148
149
.
. .
. . . . . .
Education towards self-management Self-treatment procedures
.
... 149
. ..
" .,
.
146
.. .... l49
tissue injury
. . , .. .
.. . . . . ... . . .. .
.. .... ....... .. ...... .... ..
Traumatic onset Management
128
. .. 130
..........
.
lntroduction
CHAPTER NINE
125
.... 126
Patient Management
Active
.
............... 126
Use of symptom responses to determine loading st rategIe s
. .
. 123
. .... 123
.
Symp tomat ic presentation
Review process
.
.
.
.
. .
.
,
.... 151 . . 151 151 ". 152
Ixi Ch roni c presentations
"
.
" ..... ....... 154
Late traumatic p r e se ntati on s - abnormal tissue
. 154
Late insidious onset presentations - abnormal tissue
.154
Intra-articular derangements
. . .
.
. . . . .
..
. . . . .
. ..... .
..
.
.... .
. . .
....
. . . . .
155
Chronic pain states - abnormal tissue/abnormal
response
.........................................
..155
Abnormal tissue, normal stresses - Dysfunction Syndrome
.. ..
Articular dysfunction
......... ..... .... 156
Education towards self-management
.... . . . .
. .
.
. . .. .
.. .
.
. ..
. .
.
..
.
. . . .
.. . . .
.
...
156
157
.
Self-treatment procedures reqUired to remodel articular dysfunction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.. . .
Musculotendonous or contractile dysfunction Education towards self-management
158
. . . . . . . . . . . . . . . . . . . . . . . .
.
.
.
.
. . . . . . . . . . . . . .
... .
.
.
.
.
.
. .
. ..
.
161
.
162
. . . .
Self-treatment procedures requi red to remodel musculotendonous dysfunction Treatment
.
. .. . .
.
. .
.
...
.
. . .. . . . . . .
. . .
.. . .
. .
162
. . . . . . . . . . . . . . . . . . . . . . .
......................................... 168
Articular Derangement Syndrome
....
Education ill self-management
.
.
. .. . .. .
....
.
... . . .. .
. . .
....
. . .
.
.
. . . .
.
. . .
.
.
...
..
. .
.
. . .
169
. . . .
171
. . . . .
Self-treatment procedu res required to reduce il1temal ........................................................... 172
derangement Chronic pain states Management
.
. . . .
.
.
. .
.
.
.
. . . . . . . . . . .
.
.
. .
. . . .
.
.
. .
............................ ............. . 182
. . . . . . . . . . . .
. . .
.
. . . .
. . . . . .
.
. . .
.
. . . . . . . . . .
.
Therapist te c hniques and passive modal it ies Clinician p rocedure s
....... 186
............................ ..... 186
Common Disorders Introduction
... 185
...............................................
Passive modalities
CHAPTER TEN
184
. . .
. .
.
. . .
. .
.
.
. . .
. . . . . .
.
.
. . . .
.. 190 .
................................................ .................. 190
The spine and peripheral Joint problems Rotator cuff tendonitis
...... .... .
. . .
..... .....
... 191
. ............................... ..... 193
Natural history and clinical course of rotat o r cu rf tendonitis
. .... .. . .
Management a n d self-treatment exercises Capsul it is of the gleno-humeral joint Natural history Management
(, fro z en
. . .
.
...... 196
...................... .. 197
shoulder')
... 204
... ............................ ...... 205 .205
Self-treatment exercises
..... 206
Clinician mobilisations
............... . 209
Late r a l e pic on dyl itis ('tennis elbow')
..... 215
xiii The natural history and clinical course of lateral epicondylitis
... 216
Self-treatment exercises
.....216
'Pseudo' tennis elbow or elbow derangement Self-management exercises
... 218
............
Carpal Tunnel Syndrome
..218
.
....... .
..
.
.
. . . .
... 224
.
Natural history
..226
.
Management
.
.
.
..
226
. . . . . .
Tenosynovitis - de Quervain's Syndrome, ('trigger finger')
228
Management
..... 228
Dupuytren's Contracture
... ........... .... . ............. 231
Management
............
. ..232
Bursitis Overuse injuries
232 . . . . .
.
. .
. . .. . .
.
....233
. . . . . . . . . . .
Management of overuse injuries
...237
'Groin strain' or adductor strain
...238
Management and self-treatment exercises
. ............240
Achilles' tendon injuries
241
Management and self-treatment exercises
................. .243
Patellofemoral joint pain
...... .24 5
Clinical presentation
............... ............. .. .
.. .....248
Natural history
........ 249
Management
.
... ....... ......
Mechanical diagnosis and therapy
............250
........ ........
Sell-treatment exercises Degenerative joint conditions losteoarthritis
..
.
.
.
.
.
.
.
.
.
Lateral ankle sprains
. . .
. . . . .
. . .. .
.
.. . . ...... .
.
.
.
... ..
. .
. . . . . . . . . .
. . . . . . . .
.
.
.
.
.
.
.
.
.
. 257
. .260
.... ........265
Management of ligament ruptures and sprains . . . . . . . . . . .
.
.
.....
........... .
.
. . 255
.
Management of degenerative joint condiLions Self-management exercises
Self-management
. .2 51
.........2 52
........ 265
. . . . . . . . . . . . . . . . . .
. . . . . . . .
267
CHAPTE R ELEVEN Cl inical Reasoning
............... . ........... .
Introduction
.....
.... ..... . 273
......... .....
Elements that inform the process of clinical reasoning ..
Data-gathering Knowledge base Clinical experience
.
.
. . .
. . . . .
.
.
.
.
.
.
, ... ....
.
.
Errors in clinical reasoning
,
.
.
.
.
. .. . .
.
. . .
. . ..
.............
.
.
.
.
.
. . .
.
.
.
.
.
. . . . . .
............
274
.
.
280
. ... 280
............ .
An example of clinical reasoning
.
.275
.
..................
.
. ..., ...... 27 4
. .. . .................
Cognition and meta-cognition
.
273
...... 281 .
.
.
. . . . . .
.
.
.
. .
.
..
.
...282
Ixiii .... 282
History-taking Physical examination
........ 285
Education anel active mechanical therapy
..... 286
Conclusion
.............. ...... 288
R eferences
. . . . . . .
. . . . . . .
. .
289
.311
Glossary of Terms Index
. . . . . . . . . .
..........
.. .................... ... 315
xiv
I
List of Figures
1.1
Chronic conditions in the general populaLion. Rate of reporting selected conditions per 1,000 adults
1.2
. .
.................
............
. .............. 8
. . ... 9 .
.
. .
. .
Reported prevalence in the general population o[joint problems by men and women
1.5
.......... 9
Musculoskeletal symptoms in those attending primary care
1.6
11
Distribution of different locations of musculoskeletal symptoms in the general population
1.7
. .
. . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. . 13
Distribution of different locations of musculoskeletal symptoms in those visiting primary care
2.1
.
Reported prevalence in the general population of certain joint problems by age groups
1 .4
. 8
Prevalence of joint problems in the general population by age range
1.3
.
..... 14
Time course of cellular activity following tissue injury
.
. 26
Sir Astley Cooper engravings Plate II
....
. ..... ..... .
.. .... ....
. .. ........ 38
Plate III
.. .... 40
Plate IV
......... 42
Plate V
44
Plate VI
.
Plate XXII
..... .............. .
Plate fu'ZllI Plate fuY...V
46
. . . . . .
. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . .
. . .
.
.
.
.. 48 .
.
. . . . . . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
Plate XXVll
. .
.............. .. 104
The McKenzie Institute Peripheral Assessment sheet physical examination
9.1
10 1
56
The McKenzie Institute Peripheral Assessment sheet history-gathering
6.1
52
. '54
Plate XXVlll
5.1
50
. ..
Assessment sheet- knee derangement
. .. .. 122 ...... 180
Assessment sheet - rotator cuff suprinatus dysfunction
.
.
.
.
.
.
.
... .202
. . . . . . .
10.2
Assessment sheet- capsulitis early stage
10.3
Assessment sheet- frozen shoulder late stage
.
.
.
.
. .
.
. . . . . .
.
.
.
. . .
211
213
Ixv 10.4
Assessment sheet - tennis elbow
10.5
Assessment sheet - anterior knee pain
10.6
Assessment sheet - hip j oint OA
10.7
Assessment sheet - ankle inversion sprain
Photos 1-118
. . . . . .
.
. . . . . . . . . . . . . . . . . . . . . . . . . .
222
........................ 253
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
153
-
263 270 268
List of Tables
1.1
Prevalence of musculoskeletal problems by site
...... 12
in general population
1.2
Prevalence of musculoskeletal problems in those who seek treatment
................ 13
1.3
Diagnosis given by clinicians for shoulder conditions
2.1
Matching the stage of the condition to management
3.1
The state of the tissues
61
Description of a shoulder joint dysfunction
6.2
Directional preference
71
Disability questionnaires
7.2
Traffic Light Guide
8.1
Classification chart
. . . . . . . . . . .
. .
. 18
. . 25 .
. . . .
.
.
77
...... 109
.. .. ...... 119 ... 125 .
. 127 . .
..... 144
INTRODUCTION
Introduction
M echanica l disorders a ffecti ng the soft tissues and joints of the human
extremities are encountered d aily by general practice p hys icia ns
,
physiOlherapists, chiropractors, osteopat hs and a myriad of alternative health care providers. vVhether the prob lems arise subsequent to injury or from inflammatory or degenerative processes, the
consequences are pain, stiffness and limitation of function or activity, or all of these. The duration of impairment, pain or di sability can vary from a few d ays in the case of minor injury to months or even years in some conditions fortunately a ll hving bodies, human and animal, have remarkable c apac i ty to heal and repair. A nimals in the wild can recover and survive from a p paren tl y catastrophic i njury Skeletal remains of p rehistoric
man
show similar ability to survive
b oth injury and degeneration The natural healing process h as allowed living things to recover from all but fatal injury The remodeling of soft tissue and bone alike is evidence of the body's inherent capaci ty to repair, adapt and survive
.
Our ancient fore b ea rs had no knowledge of the mechanism of hea ling or medication to relieve pain. They must have d iscovered in very
early times, however, that failure to restore activity levels mean t certain rapid decline and eventu al death. F ortunate ly mankind survived, and did so in those e a rl y times without the expertise of numerous therapists and physicians. A century ago, only those suffering severe injury causing fracture or
dislocation sought the services of a phy sician E ve ryday problems such as sciatica, l u m b ago tennis elbow, hou se m aid's knee and wry ,
neck were mos t o ften manage d with home remedies or by bonesetters.
A 'hot iron on vinega r and brown paper' or 'stinging nettle' were comnlOnly applied as counter-irritants to painful di sorders until the
nat ura l healing process brought eventual reli ef People in pain went about theil- daily tasks. Minor aches and pains were frequently disregarded, considered trivial and were viewed as another of life's hurdles either to overcome or to bear. They pu t up with the pain of repetitive strain and occupational over use until their structures adap ted At the beginning of t h is century, to do otherwise would have meant starvati on
.
11
211
NTRODUCTION
THE HUMAN
EXTREMITIES: MECHANICAL DIAGI'\IOSIS
& THERArY
The chemical and mechanical tools and the economic capacity that allow us to apply many diverse treatments to musculoskeletal disorders for the alleviation of pain and disability have only been available in comparatively recent times. Improved social support structures now sanction sick leave for workers with m uscu loskeleta] problems. These conditions have created an extremely costly situation for society In the Western world in modern times, the family medical practi tioner, the ph ysiotherapist, naturopath, acupuncturist, chiropractor, osteopath and others are consulted to provide relief and reassurance to those with injuries and aches and pains thal long ago would have been silemly borne until nature had her way. In modern times a common response to musculoskeletal complaints is to seek help from one or many of those offering a solution. So successful have modern health care providers been in creating patient dependency on therapy and therapists that the advice usually proffered by one layman to another complaining of pain is routine 'you had betler go and see someone about thall' There exists in Western populations a widespread belief that for healing to occur it is essential to have some son of treatmen l. Unfortunately, clinicians in training are commonly led to the same belief by their teachers. The desire of the public to receive treatment for many minor injuries or pains has led to an explosion in the demand for services and expenditure within health services worldwide. This demand has occurred especially in the field of phYSiotherapy services. As an example, in 1953, in the city of Wellington, New Zealand there
were
seven physiotherapists serving a population of
138,000 people In 1998, 61 clinics served
a
popu lalion of 1 S9 ,000,
a ratio of one therapist for every 2,600 people. There is no evidence to suggest that the prevalence of musculoskeletal problems in the community has escalated in a similar way The increase in consumption of therapy services seems hard to justify and more difficult to explain. Only a small perc e ntage of musculoskelelal injuries actually require profeSSional assistance during the period of healing and repair Patients may need education and advice about the most effective way or returning to full [unction following soft tissue trauma, but offering treatment of dubious efficacy only detracts from the imporlance of the patient's role in this recovery
I NTRO DUCT I O N
I N T RO D U C T I O N
Patie n ts w ith dege n erative J oint disease and chroni c m u s c u l o s k e l e t a l p ro b l e ms certainly req uire educa t i o n in se l f-manageme n t , b u t i t is hig h l y unl i ke l y t hat t h e y re q u i re traditional modal ity - b ased passive physi o the ra p y Hea l th c a re providers allied to m e d icine have t w o gre a t persisting han d ica ps T he firs t is t h e lack o f un d ersta nd i ng o f the meaning and si gni fic a n ce o f t he p h ra se ' n a t u ral history ' . The term is rarely pa rt o f the voca bu l a ry o f o u r teachers a n d i s h ard to fi n d i n text b o o ks used in physi othe ra py, c h i ro practic and osteo p athic scho ols of e d u c a ti o n . Ye t i t i s u p o n t he na t u r a l histo ry of mechanical d iso rd ers t h a t so many of u s re l y For our su rvival as health care p ro fessio nals . The second great handica p is t he inab i lity o r rel u c tance of those in cli n ica l p ra c t i c e to a c k n o wledge d e feat. There is a gene ral t e n de ncy
by cl inicians [ 0 persi s t ,,,v i th treatmen t l o ng a fter a l l available methods have been fou n d wanting. There seems to be a reluctance amo ng heal th care p ro v ide rs (0 a c k n o w led g e their limitati o ns . The res u l t i s a co n t in u in g sea rch fo r a n elusive p a n a cea - a ne w techniqu e o f
man i pulation o r a n e w fo r m o f e l e c tro therapy that will so lve the p ro b l e m w h e n a l l e l se has fa i led. It is n ot ge ne r a ll y recogn ised tha t the re is l i ttle sci e n t i fic e v i d ence su p p o rt i ng the use of any of the current phYS i o t herapy m o dalities for the t rea t m en t of muscu l oskeleta l disorders . The re is , ho wever, am ple evide n ce tha t the a p p l ica t i o n o f m o ve ment and the rep e a t e d and prolonge d fu n c t i o n i n g o f a l l structures a ffected b y injUly pro vides the best sti m u lus for repair a n d the best environment
in
w h ich to
achieve fu ll recove ry of fu nction a n d p a i n - fre e status. W h ere s i gni fi c a n t
inj u r y c a u s e s
t h e p a t i e n t p e rs i s t i ng p a i n ,
impa irmen t o f funct ion and re d u c e d mobili ty, phYSi othe rapy by way of e d ucation and su pervision may b e indicate d . Physiothera py canno t acce le rate healing , b u t education a n d supe rvision can ensure that healing is not d isru pted and that the environment fo r re c o v e ry is optimal . T h e main [u n c tion of the physiotherapist o f the fu t u re w i l l be t h e e d u c a ti o n a n d e nlightenment o f
the inj u red and i gn orant .
P a t ient education is o n e o f t h e mai n t h e mes o f this tex t . Patients
m us t be p ro v id e d w i th sound explanatio ns and sho uld comprehend the n eed t o m a intain the c o rre c t envi ronment fo r m a naging the i r p rob lem. It i s a lso necessary fo r the patient to u nderstand that the
13
4/ 1
N T R O D U CT I O N
TH E
H U MA N E X T R E M I T I E S :
M EC H AN I CA L
D I AG N O S I S
&
T H E RA I'Y
recovery of fu nc ti o n can only com mence fo l l o wi ng a d e qu a te healing a nd repair, and requires an ap p ro p ria te reha bilitati o n p rocess . These p ro cesses may take time , but rec ove ry is i mposs i b l e wi tho u t t h e p a tien t s a c tive in vo lvemen t . '
This text does n o t a t temp t to p ro v i d e the rea d e r w i t h a d e ta ile d description o f diagnos t ic proce d u res usu a l l y e x pe cted i n a book a b o u t muscu l oskeletal d iso rd ers o f the e x t re mi t ies . I no lon ge r b e l i e v e t h a t the p recise i d e n t i ficatton o f the stllJ c t u re i n v o l ve d i s n ecessa ry o r a p r e re q u isi t e fo r the p rescri p tion and s a fe de l i v e ry o f a p p ro p ri a te mecha nical th e ra p e u t i c i n t e rventio ns ; n o r d o I be l ieve it is a l ways p o ss i b l e to make such an i d en t i fica tio n . irres p e c t ive o f t h e stru c t u re in volved , ulti matel y the mechan i c a l the ra p e u tiC stra tegy is d eterm ined s o le ly from the res p o nses obtained fro m tissue l o adi n g a n d the e ffec t t ha t l o a di ng h a s o n symp to m a to l ogy T h i s b o o k is not i n te nd e d t o fi l l a g a p for those in search o f an a d d i t i o nal t e ch n i q u e o f m o b i l i s a t i o n o r mani pu la ti on
.
This b o o k is written to e n c o u rage a p p ro p riate heal t h c a re pro fe s s i o na ls t o p ro v id e s o u n d and e ffe c t ive sel f-ma nage m e n t (o r t h e i r pa tien ts The a d vice p rov id ed is a imed a t all o w in g t h e p a t i e n t t o .
take res p onsi b ility fo r h is o r her o wn re c ove ry I t i s h o p ed t ha t i n depa rting fro m the u s u a l ' hands on' p a thway s o d e a r to t h e h e a rts o f many cl inici ans , the e mphaS iS will s h i ft fro m p a t i e nt d e p e n d e ncy o n therapy t o p a tien t i n d ependence . The truth is t ha t t h e v a s t n u m be r o f treatments d elivere d b y h e a l th ca re providers fo r t he a l l e v i a t i o n o f muscu loske l e ta l aches and pains are usu a l l y u nn ecessa ry ; cena i n l y their e ffe c t i v e n e s s i s un p ro v e n
.
E v e n t u a l l y, a ll p h YSio the r a p i s t s
i n v o l ve d i n the fie l d o f o r t ho p a e d i c m ed i c i n e and th e ra py m u s t p ro v i d e t h e e du c a t i o n t h a t w i l l e n a b l e t h e p a t i e n t t o p ra c t i c e '
au to therapy . '
The m a i n themes to uched on h e re a re d eve l o p ed thro u gh o u t the b o o k . The prevale nce o f musculoske l e t a l d iseases , t he l a rge nu mbers of p e o p l e w h o have p ers i s ten t pro blems a nd the lack o f e fficacy o f many commonly used tre a tments are examin e d . The h ea ling process of s o ft tiss ue inj u ries , the mechanic a l , in n a mma to ry and c h ron i c pain m e c h a n isms , and the m e ch a n i c a l s yn d ro me s o [ t h e M c K e n z i e ap pro ach as re lated to the p erip he ra l j oints are d escribed l n fo m1ation o n how t o gather data about pa tie nt p roble ms assess cha n ge s a n d ,
manage di ffe re n t pa tien t conchtion s i s a lso p resented . Some c o m m o n d i s o r d e rs are d escrib e d and a ppro p ri a t e s e l f- t re a t me n t s t rategies are
I N T RO D LJ C T t O N
recommend ed . I t i s hoped tha t thi s text w i l l s u p po r t t h ose c lini c i a n s
who are p e rple x e d by t h e fa ilure o f many interven t i o n s to ' c u r e ' their p a tie n ts' p rob l e m s , a n e! w h o s e e k e n d o rseme nt for an a p p roach th a t de m a n ds p a t i e n t i nv o lvement a s t h e o n l y l ogica l w a y forward for t h e physi o t he ra p y p ro bsi o n .
I N T R O D LJ CT t O N
15
S I I N T RO D U CT I O N
T H E H U MA N EXTRE M I T I E S : M E C HAN I CAL D I AG N O S I S & TH E RAPY
C H A PTE RON E
1: Musculoskeletal Problems
Introduction
This [irsL chapter is intended to give a brief overview of the problem of musculoskelelal pain in the general population. Health problems
are located in broad contexts and should not be considered only through the narrow focus of the clinic. If we know more about the prevalence, the natural history, and the effect of treatment upon a conditio n, then our understanding of a clinical problem is considerably improved T he size of the problem, its persistence and the health care services' ability to deal with it also have repercussions upon management Diagnosis in musculoskeletal medicine is in its infancy. Wit h i n spinal prob !ems speCific d iagn oses have been replaced by broad, non -specifie
categories (Spitzer 1987; Rosen et al. 1994) In peripheral problems, specilic diagnostic criteria are used more widely with an underlying assumpLion of reliability, which is, however, barely endorsed by the studies available. This chapter will also look briefly at some of the issues surrounding the problem of making a diagnosis. The implicaLions that Lhese issues have upon the management of musculoskeletal problems will be discussed. Prevalence
Musculoskelewl conditions of al l types are extremely common
in
Lhe general population They are frequently found in population surveys when individuals not receiving treatment are asked abouL problems. These studies give a re a sonab ly accurate picture of the extent of in [ he UK
a
particular problem in the community. Population surveys
show that musculoskeletal problems, spinal and non-spinal,
are the most frequently reported long-standing illness in all age groups (Bennett
et
al. 1995)
There is a linear increase in these conditions with age. Less th an 10% of Lhose under 34 are affected, rising to 32 49% of those over 75 (Bennett eL al. 1995; Badley and Tennant 1992) After 45 years of age -
over 10% of the population are affected by multiple jOint problems.
Difficulty WiLh daily functions and lack of independence, as a consequence or these problems, rise linearly to ab o u t 50% in those over
H'J
(Badley and Tenna11l 1992)
17
81 C1-1 Al'TE RON E
THE HUMAN
EXTREMJTlES:
Figure 1.1
Chronic conditions in the gene ra l population. Rate of
MECIIANICAL DIAGNOSIS & Tt-IERArY
reporting selected conditions per 1,000 adults. UK
(Bennett
et al. 1995). 160 140 120
° °
D.
100
�
so
" "" ;; �
60 40 20 0 HC;.1r[ & CirclIlatory problems
Musculoskelelal
prohlems
Rcspirillory prohlems
Digc.::.Livl' system prohlems
Site of condition
Figure 1.2
Prevalence
by
of joint problems in
age range. UK
the general population
(Badley and Tennant 1992).
Ml sO u u
5
-;;; >
�
0..
?f!-
40 }O
1·2
§:']
multiple
r;
20 ](1
i!il
t-----,
J6·24
25·}4
',)·44
'IS-54 Age group
Problems
were
i ,·(1·1
65-/4
75·84
,l.J'
(in decades)
evenly divided between back problems, 'Olher bone
and Joint problems', and 'arthritis and rheumatism' (BenneLt 1995) While the prevalence of spinal problems reached
a
et
plateau
al. in
those older than 55, non-spinal problems continued to increase after this age Musculoskeletal problems are more common in women aL all ages. Surveys of general populations in oLher countries give Similarly significant proportions thaL repon all types of musculoskeleLal symptoms. In Denmark, long-standing musculoskeletal problems are
p re valent in 13% of the population, and make up 30°/r, of all chronic illness (Bredkper 1991) They constitute the large':>t cause of chronic disease in Finland (Sievers and Klaukka 1991). In the US the prevalence rate of musculoskeletal illness is 30% (Cunningham and Kelsey 1984) and in Canada 16(X) (Lee et al. 1985) In Sweden
CHAPTER ON E
MUSCULOSKELETAL PRORLEMS
Figure 1.3
Reported prevalence in the general population of certain joint problems by age groups. UK (Badley and Tennant
32 30 2H 26
,y �. E 0
� �
-
24 -
22
-
-+-
"nklc
- .--
hip
-
:& -
/ /
"houlder
/
- - x- - hand - *"
- knee
"
-'-[ow back
25·3-1
1992).
-1)·)-1
35·4-1
Age group
55·6-1
65·7i
(in decades)
75·84
85+
10 - 20l)6 of the sample population reported obvious musculoskeletal
pain, most with pain persisting for more than six months (Brattberg 1989), and in Lhose over 45 years of age, 35% reported long-lasting JOint complaints (Larsson et al. 1991) There is some evidence of an increase in reponing of musculoskeletal problems and consequent
health service use in Sweden
in the last few decades (Sievers and
Klaukka 1991; Slalis and Ruusinen 1991) There is some suggestion Lhat social and economic factors, as well as medical ones, playa role in determining wl1ether a person with these symptoms goes on to
develop disability related to their musculoskeletal impairmenL (Cunningham and Kelsey 1984) Reported prevalence in the general population ofjoint problems
Figure 1.4
by men and women. UK (Badley and Tennant
1992).
70 60 50 40
/
,y
. •...... .•.. .... .•...
30
. ..
-+-women
20
- -.- - men
10
0 16·24
3,11
45·54
55·64
hi ;4
Age group
(in decades)
7+85
85+
19
10
I CHArTER ON E
TH E
HUMAN EXTIUMITI ES:
MECHANICAL DIAGNOSIS
& TI-I ERArY
A common musculoskeletal problem is shoulder pain. Populations in Sweden and England who were 50 or older reported painful shoulders in 14 - 34% of the samples investigated (Bergenudd et al. 1988; Allander 1974; Chard
et al.
199 1; Chakravarty and Webley
1990) In a Nigerian village, 14% of a commumty-based sample were found to have shoulder problems (Adebalo and Hazlernan 1992) Across all ages, 7% of the population have been found to have shoulder conditions. This makes it the most frequent musculoskeletal complaint after back and knee problems (Badley and Tennant 1992) Osteoarthritis is the most common sou rce of Joint problems throughout the world. This disease accounts for considerable disability to individuals, as well as a considerable cost in health services to society (Felson 1988; Felson and Zhang 1998) The prevalence of osteoarthritis from the middle years onwards is about 5%, although obviously this increases dramatically with the oldest groups (Petersson 1996; Felson and Zhang 1998) RadiographiC degenerative changes become so common in older age groups that it can be said to be normal These changes are present in the majority of people by 65 (Felson 1988); however, only 30
-
40% of those
with radiographiC changes have symptoms (Felson 1988) The hands, knees and hips are the most common sites of osteoarthritis, in that order (Petersson 1996)
For instance, the prevalence of knee
osteoarthritis reported by several studies ranges from 12
-
38% of
subjects surveyed (Spector and Hart 1992) Osteoarthritis was the diagnOSiS given in about a third of patients attending an orthopaedic outpatient department in the UK (Byles and Ling 1989)
In summary, about a quarter of all populations surveyed have musculoskeletal conditions, including osteoarthritis. This is the figure of those affected in the general community, not those seeking treatment. There is increasing prevalence with age, and women are more at risk than men. Musculoskeletal conditions of all kinds constitute one of the biggest causes of chronic d isease.
Health care The high prevalence rate in the general population is renected in the frequency with which individuals consult meclical pracLitioners with musculoskeletal aches and pains For instance, in the UK, 15% of the population consulted their GP because of a musculoskeletal complaint in 1991 (},/lcCormick et aL 1995)
In three general
CHAPTER ONE
MUSCULOSKELETAL PROBLEMS
practlces, a b ou t 15% of GP consultations related to spi nal and non spi n al Joint and soft tissue problems (Hackett et al. 1993) The consulting raLe was low among Lhose under 44, but then increased sLeadily with age, with rates hi gher among women of all ages. The
most common three groups of pro b lems with roughly equal ,
propomons, related to back pain, arthropathies and 'rheumatic complaints', including otherloinL, muscular and soft tissue problems. Some 5°;(, of general practice consultations are reported to be related to shoulder disorders (van der HeiJden et al. 1997) Two per cent of the total population consulted for tendonitis or bursitis, mostly at the shoulder and elbow (McCormick et al. 1995) In
a
rural F i nnish
popul atio n musculoskeletal problems accounted for 27% of adult ,
visits to their primary care physician, and 21 % of all visits (Rekola et
al. 1993)
Figure 1.5
Musculoskeletal symptoms in those attending primary care. Finland (Re/wia 1993).
TOlal
7634
visilS over 2
weeks
o Palienls with musculoskeletal symptoms
Not everyone consults with these types 01 problems
In
Ch ard s (Chard '
and Hazleman 1987; Chard et al. 1991) surveys of 70-year-olds,
about 25% had shoulder pain O[ the surveys, only 14% and 35%
e spectivel y of those with pain sought medical attention; of these, in
r
one survey, o n ly 40% were gi ve n any form o[ treatment. Frequently patients become disillusioned with health care, and after treatment failure they stop attending (van der Windt et al. 1996; Chakravany and Webley 1990) Musculoskeletal problems constitute an extremely common health p ro bl e m in the community, with the burden being greatest in older
populations. They represent the most common cause of persistent symptoms and functional disability in the general population. They are also a very common reason that people seek health care services.
111
121 CHAPTER. ON E
THE HUMAN EXTRJMITIES: MECHANICAL DIACNOSIS & THERAI'Y
The site of the problems
Clearly musculoskeletal complaints are a common cause of morbidity in
the population at large and represent a large burden LO health care
organisations. In this instance we are concerned specifically wah problems
in
the limbs.
In
the general population the prevalence of
peripheral joint problems is much greater than spinal problems (Badley and Tennant 1992; Cunningham and Kelsey 1984) In surveys in which the site of all disorders has been collected less than 20% report spinal problems, whereas 44
-
49% report pain in the
extremities (Badley and Tennant 1992; Cunningham and Kelsey 1984) Half, or more, have symptoms in more than one site (Larsson et
al. 1991; Cunningham and Kelsey 1984), with the most common
sites affected being the shoulders, hands, knees and hips. Table 1.1
Prevalence of musculoskeletal problems by site in general population
Site oj pain
lumbar
Badley
Cunningham
10%
17%
Larsson
(all spinal)
cervical
6%
shoulder
7%
7%
15%
elbow
3%
4%
6%
wrist
3%
3%
gOAl
hand
7%
7%
15%
hip
5%
8%
13%
knee
10%
13%
17%
ankle
4%
4%
10%
foot
5%
3%
6%
However, 'vvhen it comes [0 those who seek health care services [or musculoskeletal problems, more people WiLh spinal pain appear [0 come forward, as non-spinal joint and soft tissue problems represent about half of the load of musculoskeletal morbidity seen in clinics (Hackett
et
al. 1993; Peters et al. 1994; Hockin and Bannister 1994;
Rekola et al. 1993) Comparing data from different countries suggests that spinal problems
in
the general population represent about 259{)
of musculoskeletal disorders (Cunningham and Kelsey 1984; Badley and Tennant 1992); however, in primary care they constitute nearly half of all musculoskeletal conditions (Rekola
et
al. 1993; Hackett
et
a1. 1993; Peters et al. 1994) In surveys of one GP praC[lce (Hackett
et
al. 1993), one orthopaedic out-patient department (Hockin and
MUSCULOSKELETAL PROBLEMS
Figure 1.6
CHAPTER ONE
Distribution of different locations of musculoskeletal symptoms in the general population. US
(Cunningham and
Kelsey 1984). 20 ,-----IH
-j------
16
c
I-I 12 10 8 b 4
�o0'
Localioll of symptoms
Bannister 1994), both in the UK, and one practice in a rural primary care setting
in
Finland, the average prevalence of problems by site
was as l-ollows Table 1.2
Prevalence of musculoskeletal problems in those who seek treatment
Site
of pain
Hachett
Hochin
Rehola
lumbar spine
30%
35%
18%
cervical spine
15%
12%
20%
shoulder
22%
8%
14%
SOrL lissue inJunes
11%
knee
10%
21 %
ll%
ankle/fool
6%
20%
11%
Lennis/golrer's elbow
4%
4%
2% 11%
wnSl/hand hip
4%
These ligures suggest that peripheral musculoskeletal problems represent at least half of all musculoskeletal conditions seen
in
primary
care and hospital settings, and that the most common sites of peripheral problems that patients seek help for are shoulders, knees and ankles However, they also show that the proportion of different conditions may vary quite considerably in different clinical settings.
113
141 CHAPTER ONE
THE HUMAN EXTREMITIES:
Figure
1. 7
MECIIANICAL DIAGNOSIS
Distribution of
di.fferent
& THERAPY
locations of musculoskeletal
symptoms in those visiting primary care. Finlal1d
et al.
(Re/lOla
1993).
25 ,--
20
15
10
o Neck
Back
Shoulder Ankle & Hand & FOOL \VrisL
Knee
HilJ
Thoracic
llho\\'
Ullin
Localion of symptoms
Natural history and clinical course Although the natural history of musculoskeletal pro blems is
frequently thought to be good and the outlook with tre J t m enL is
often viewed optimistically, the evidence s u gg es t s oLherwise As several of the above studies make clear, large numbers or the population have t h ese conditions for long periods or ti m e (Bennett et
aL 1995; Bred kj aer 1991; Sievers and Klaukka 1991; BraLtberg
al. 1989) Studies show
in c re asin g prevalence
ct
or t h e s e conditions
'vvith age, su ggesti n g that degenerative changes and cumulative trauma
has a role in their aetiology and chronicity (Badle)' and Tennant 1992; Cunningham and Kelsey 1984)
For instance, many studies have found Lhat shoulder pain has pe rsist e d or recurred in at l east 40% of those patienLs studied when
followed up for a year or more. Treatments including corticosteroid
injections, anti-inflammatory medicine (NSAlD), manipulation and physiotherapy have often conferred only short-term benefit (Croft et al. 1996; van de r Windt et al. 1996; Be rge nudd et at. 1988 ; Vecchio et
al. 1995; Cha rd and Hazleman 1987; Wmters et al. 1999) Variables
that p red i ct ed poor outcome were concomitant neck pain (odds ratio 28), high baseline pain s c ore (odds ratio 20),
a
long duration of
symptoms at presentatlOn (odds ratio 05), and initial referral to p h ysi o th e ra py (odds ratio 0:4, compared to no treaLment or m e dication only) (van der Windt et al. 1996).
Ci-IAI'TER
MUSCULOSKELETAL r'ROlILEM$
Many
patients do not persevere with seeking treatment despite
persistent
symptoms They frequently try health care once or twice
.
When th is does not bring relief they cease attending, but are left
with chronic symptoms th a t they are forced to tolerate. This group with persistent symploms may be as high as 50% of those originally coming forward for treatment
and
We b le y
resolution of
(van der Windt et al. 1996; Chakravarty
1990). This can give the mis ta k en appeara nce of a
problem that in fact persists and is simply tolerated,
and an illusion of treatment efficacy that is il lu so r y There are suggestions in the literalure
lhat shoulder pain recurs, and that many
individuals may have several episodes p rior to the problem becoming chro nic (Winters et al. 1997;
van der Windt
et
Cl1. 1996)
Frozen shoulder is a condition that is frequently said to recover spontaneously
wi thi n six to eighteen months (Rizk and Finals 1982)
Ho w ev e r certain studies show its effect can last for much longer, ,
and that treatment has little effect on outcome. Bulgen
et
al. (1984)
compared intraarticular sLeroids, mobilisations, ice the rapy and no trea tment over a six m on t h period and found that all groups -
irnproved, but lhat lhe re was little l ong- t e r m advantage many regime When these patients ,vere reviewed around four
trealment
years later, aboul half were still found to have persistent aching or restriction of movement, with greater restriction in those patie n ts who had
received mobilisation (Binder
et
al. 1984) Shaffer
et Cll.
(1992) also ["ound about 50% of their study group had mild pain
and/or stiffness when reviewed at about seven years. In a long-term Coll o w-up of patients
with rotator cuff tendonitis who were treated
with NSAlDs, i nj e c tio n or exercise, a yea r and
a half later (Chard
et
nearly 50% were still symptomatic
al. 1988)
Wadsworth (1987) Slates lhat conservative management is successfuI
in 90% of cases of lateral epicondyhtis Although patients frequently im pr ove with ultrasound or injection,
when reviewed up to five years
laler about 50% of study groups had pain and functional limitations, al t h o u gh few had so u gh t further treatment fo r the problem (Binder and Ha z le m a n 1983; Clarke and Woodland 1975; Hamilton 1986) '
Tennis elbow' clearly has a high rate of relapse and failure to resolve.
The evidence would thus suggest that the experience of persistent musculoskeletal common
problems, which are res istant to treatment, is very
in the general population The lack of long-term follow-up
and the withdrawal of patients from therapy generaLe the illusion of
ONE
115
161 CHAPTER. ONE
THE
HUMAN
EXTR.EI\;\ITIES: MECHANICAL DI AGNOSIS & THEI1.APY
therapeutic efficacy for many interventions. However, for a vast number of patients, the reality is persistent pain and functional limitations.
Systematic reviews of commonly used treatments Systematic reviews of randomised controlled trials, because they pool the results of several studies, are said to be the optimal way to Judge the efficacy of different treatments (Gray 1997) Systematic reviews frequently rate the trials poorly against the criteria by which they judge the methods used in that trial. They also generally find little firm evidence to support c ommonly used interventions for musculoskeletal problems. "The evidence in favour of the efficacy of steroid injections for shoulder disorders is scarce" (van der HeiJden et aL 1996) "There is little evidence to support or refute lhe efficacy of common interventions for shoulder pain" (Green et al. 1998). This review looked at treatment with anti-innammatory (NSATD) tablets, injections and physiotherapy "There is evidence that ultrasound therapy is ineffective in the treatment of soft tissue shoulder disorders..
Evidence for the effectivel1ess of
other methods of physiotherapy is inconcl.lsive" (van der Heijden eL al. 1997) One group reviewed the use of ultrasound, ionisation, oral NSAlD and steroid injections for lateral epicondylitis and "concluded that there was insuffiCient
SCientifiC
evidence to support any of the current
methods of treatment" (Labelle et at. 1992)
A systematic overview of steroid injections lor lateral epicondylitis found a favourable treatment effect at six weeks, but a lack of long term effect after this (Assendelft et aL 1996). "There seems to be little evidence to support the use of ultrasound therapy in the treatmenL of muswlosheletal disorders" (van der Windt et al. 1999) Systematic reviews and meta-analyses have an inherent problem in that they are only as good as the clinical trials they draw their conclusions from. In the attempt to make a general conclusion, trials
with different procedures, measuring tools and outcomes are lumped together with the assumption that greater generalisable 'truths' can be gained from disparate studies. While the quality of methods is
C H A PTE R ON E
MUSClJl.OSKEl.ETAl. PROlILEMS
strictly adhered to, the quality or exact type of intervention may be obscured Although it is certainly pertinent to question the validity or their conclusions, in all instances the message from these rev iews cannot be ignored. They testify to the inconclusive treatment effect of many commonly used interventions These findings in fact acc ord with what is clear from the
epidemiological literature outlined earlier - that many people have persistent or recurrent musculoskeletal problems that are either resistant to treatment or respond only temporarily. It suggests we should begin to reformulate the problem - not what can we do for our patients, but what can our patients do for themselves.
This is
bound to involve exercise therapy
The only intervention that consistently appears beneficial across a wide range of spinal and non-sp inal musculoskeletal problems is exercise.
"One ((In draw a number o j conclusions, however. First, and importantly, exercise appears to be the best modality. St rengt hen i n g muscles protects the joint. Secondly, most oj the machines that plug into the wall a re acting as flashy placebos" (Clarke 1999).
"there is littl e evidence that any oj the therapies under review cause improvements in symptoms oj c h ronic museulosheletal pain or in quality oj liJe t hat outlast the therapy . ". Only two trials reported positive long-lerm treatment effects. "The treatment groups in both oj these trials re c e ived exercise" (Feine and Lund 1997).
Mter reviewing a wide range of interventions Feine found
.
.
common with other areas oj musculosk eletal rehabilitation, the evidence strongly supports exercise (except possibly in the rare case oj true radicular bach pain) and a c ogn i t ive beha vio u r al appro ach to pain management" (Haigh and Clarke 1999) "In
"Exercise
re
d u c e s pain and improves Jun cti on in patients wi t h
osteoarthritis oj the knee"
(Puett and Griffin 1994)
The available evidence does not support the treatment efficacy of many commonly used interventions for musculoskeletal problems. The one exception to this general rule is the widespread finding that exercise is beneficial across a variety of disorders. Rather than looking to short-term curative treatment solutions meted out by clinicians, we should be offering education and self-management strategies lor
patients to use which will be of long-term benefit.
117
181 CHArTER ONE
THE HUMAN EXTREMITIES: MECHANICAL D1AGN05IS
&
TJ-IERArY
The problem of diagnosis Musculoskeletal problems about the shoulder are clearly common. This affects about 10% of the population at some point, and 59;', of all consultations in general practice relate to pain about the shoulder (van der Heijden et al. 1996, 1997) What sort of problems are these) The commonly given diagnoses by GPs and physiotherapists in the
UK and Holland are as follows Table 1.3
Diagnosis given by clinicians for shoulder conditions
Dia,gnosis ROlator
cuff injuries
Windt
CrofL
Liesdeh 47%
30%
Capsulitis
22%
Acute bursltis
17%
7%
Chronic bursitis
13%
9%
4%
6%
Acromio-clavicular Joint
Chard
40%
17'Y"
18%
These findings suggest considerable variety in what different clin ician s think they are seeing. These kinds of diagnoses are commonly made in the clinic and are based on the ideas and criteria proposed by
James Cyriax (1982), the founding father of onhopaedic medicine. The concepts, although widely accepted, have rarely been s u b j ect e d to detailed scrutiny Two key issues have not been fully investigated -
the validity and reliability of the tests used to make these diagnoses.
Validity relates to the ability to measure what is intended Reliability is the extent to which a measure is reproducible, or gives lhe same results, in different situations (Streiner and Nonnan 1996). If different clinicians come to different conclusions using the same test, clearly that test is of little value in deciding treatment strategies Reliability of a test between cl i ni ci a n s is a first step in evaluatmg the usefulness of diagnostic pathways to treatment. Work done in this area is contradictory In nearly 400 cases of shoulder pain, 141 were examined twice by their physician; in nearly half of these the initial diagnosis was changed (van der Windt et 01. 1996) In other words, on subsequent analysis the GPs altered their diagnosis.
Of these patients, 120 were referred to a physiotherapist who also diagnosed the patient according to tne same diagnostic critena. Cohen's Kappa is the statistical test used to evaluate agreement between clinicians as it takes lnto account the proportion of agreement that may occur by chance (Srreiner and Norrnan 1996) The overall strength of agreement between the GPs and the physiolherapists was
C H A PT E R O N E
M U S C U L O S K E L E TAl P RO B L E M S
Kappa 0 . 3 1 (Li e sdek e t al. 1 997) This re n ects only a ' fa i r' concordance betwee n t he c l in i c i a n s a n d s e r i o usly q u e s t i o ns the re h a b i li ty o f these d i agnost i c c r i t e r i a i f d i ffe r e n t exa miners can rea c h such d i ffere n t c o n c l u si o n s . H o w e v e r , e x p e ri e n ce d t h e r a p i s t s u sing t h e C y ri a x
eval u a t i o n p ro c e d u re we re highl y rel iable ( K a p p a = 0 87) i n se lec tin g d iagnostic cat ego ries i n 1 9 o f 2 1 patients wi th shou l d e r pam ( P e ll e chi a et
al . 1996)
P o o r leve ls o f a g ree m e n t have been fo u n d in tests used in the c l inical assess m e n t o f kn e e pro b lems . Alt hough 'w i th i n observ e r a gree m e n t' o f vari ous tests used to evaluate osteoanhri tls i s moderate to exce llent ,
'betwe e n o b s e rver agre e m e n t ' is p o o r to m o d e ra t e U ones et al . 19 9 2 : C us h na g ha n et al
1 990) F o r b o th w ithin and between observer
var i a t i o n , h is t o ry - ta k i ng is much more re li ab l y assesse d than physi cal signs , and t h e agreement between observers a b o u t physi c a l signs o nly was p o o r
U o ne s
et
a l . 1 992 )
Certai n e l e ments of the CYliax
examina t i on of the k nee h ave also been shown to have only poor t o
fai r re l i a b i l i t y These were the j u d gements t h e rapists m a d e about end fee l and the s e q u e n c e 0 1- p ain and resistance w i th m o v e ment (Hay e s et
a l . 1 994) . F o u r com monly u s e d tests t o e v a l u ate p a te U o femoral
malalignme nt ha ve also been s h o wn to have only p o o r to fair r e l iability ( Ka p p a = 0 1 t o 0 36) (Fitzgera ld and M c C l u re 1 995 )
1 t is c le a r l y w ise to be cau tious a b o u t t h e re lia b il i t y and thus the value 01' c o m mon l y used t ests . A l t h o u gh they o ften have a reasonab ly good r e co rd o f p ro d u c i n g the same resul ts when re p e a te d b y th e
same c l i n i c ia n , t h e y ge n e r a lly have a p o o r record o f p ro d u cing the same res u l ts "vh e n used by di fferent clinicians . If the tests are suspect , the n t he d ia g n oses reached by these tests m a y also be sus p e c t I n t h i s ins t a nce s hou l d we aga i n b e reform ulating t h e question? S h o u l d we some t i m e s fa v o u r ge n e ra l diagnostic p a t t e rns , wh i c h suggest trea t men t d i re c t i o ns , rather than s p e c i fi c d iagnostic criteria t hat a re u nr e l i a b l e ? S h o u l d t h e s e g e n e r a l d i a g n o s e s b e b a s e d u p o n sym p L O m a t i c histo ry-taki n g , which o ften appears t o b e m o re re l iable
t han p h y s i ca l signs? The tests t h a t a re commonly used
[0 m a k e d i a g n o s e s i n
muscu l os kel e L a l d isorde rs a re n ei t h e r proven t o b e r ep ro d U C i bl e n o r to measure wha t i s intended T h e diagnoses the mselves m a y t h e re fore b e s u s p e c t a n d rep r esen t an u n t ru s tworthy base u p o n which to e s tablish t re a tme n t p ro tocols .
119
I
20 C H A I'TE R
ON E
THE
H U M A N E XTfU M I T I E S :
M E C H A N I CA L
DIAGNOS I S
& TIH RA I' Y
Conclusions This chapter has presented t he contex tual bac kgro u n d of m usculo skeletal proble ms. Certai n facts stand ou t m u sc u loskele tal pro b l ems are one of t he most com mon conditions that affect people in the community su ch condi tions a re prevalent in all body regions, but especially in
the large j oi n ts of the shoulder, knee, a n kl e and hip
these problems are very often persistent and c h ron ic, even in those who have received trea t ment suc h patien ts frequently seek health ca re serv ices and m a ke up a signi ficant proportion of those who attend p ri m ary ca re physic ians and physiothera pists t rea tment, al though somet imes con ferring sh o rt-te r m relie f, freq u ently does not resu l t in a cure of the pro blem •
the only intervention tha t consisten t l y does a p pear to be able to confer benefi t is a se l f-management a pproac h using exerc ise and behavioural modifica tion disillusionmen t w i th p rofessional h elp an d opting out of [u rLhe r t rea tment is common commonly used treatmen t options
in
m usculoskeletal con di tions
have a very inconclusive record o f efficacy in contro lled trials and systematic reviews the valid i t y a nd reliability of a ccep ted d i agnostic categories
a re
uncerta in, a n d the extent of non -spec i fic musc ul oskeleta l problems in the pe riphery is un known . These facts suggest a fa ilure on the part of the med ical mode l , 'vv h i ch purports to d iagnose , trea t and cure . The approach out l ined in this book proposes a di fferen t model , based upon non-spe ci fic syn drome cl assi fication a nd the overwhelming logic o f endorSing the key role of sel f-managemen t stra tegies in m u sculoskeletal med icine. H a condition is very common , persistent a nd resistant to easy remecly, it is ti me that the patien t is fully empowered to dea l with these prob lems in an opti mal and realistic fashion. As clinic i ans we shou l d be offering this e mpowermen t to our pat ients
CHArTER Two
2: Soft Tissue Properties
Introduction Tl1e previous chapter has shown that pain in the perip he ral joints
and soft tissues occurs frequently in the general popul a tJ on and is a cornmon cause for see k i ng health care services. The concern of this text is the prob l e ms that affect the soft tissues of the limbs. It is thus uselul to revi e w some of the pro pe rties of these tissues including
how injury oc c u rs , the effect of inj ury, the healing process, and what can inhibit the h e aling process. As it is vital to recoll e c t that tissues are part 01- a whole being, some of the impact of behaviour on these
pro pe rties will also be cons ide re d. How these tissues maintain their function through use and a t rophy through disuse are also esse ntial
elements of appropriate management Recognition must also be made of the role oj cumulative trauma and insidious d egenerati o n in the onse t of some muscul oskeleta l problems. The clinical implications of these factors will be discussed.
Tissue injury Tissue damage may result from a discrete traum atic episo de with a sudden onset of pain, or it may arise insidi ously due to cu mu lative trauma when overuse or
d ege neration
is present Altho ug h there has
been no overt incident in these cases, repetitiv e loads can be suffici e n t
to cause mi c ro trauma or degenerative c h anges to the tissues -
overwhelm reparative
,
processes and evoke an infl ammato ry response.
Shoulder capsulitis, te n osy n ov itis and lateral epicondylitis all c omme nce with an a c ut e inflammatory period, and usually an insidious onset. Thus injury is the result of intrinsic or extrinsic factors, either a lone
or
in
c o mbinat i o n
with chronic conditions
re presentin g an interaction between the two categories
al 1997)
Wha tever
(K a nn us et
the c a use if tissue da m a ge has occurred the ,
inflammatory p ro c ess will be triggered (Levine and Taiwo 1994)
Recovery following trauma Following tissue inJ ury the proc ess that theoretically leads to recovery
is divided into three ov e r l a pp i ng phases
-
inflammation, repair and
re m odelling (Evans 1980; Hardy 1989; Enwemeka 1989; B arlo w and
121
1
22 CHAPTER Two
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERAPY
Willoughby 1992; Norris 1993). "No inflammation /
no
repair is
a
valid dictum" (Camco et al 1984) In fact, each part of lhis process is essential to the st ructure of the final result Connective tissue and muscle do not regenerate if damaged but are replaced by inferior ,
fibrous scar tissue (Evans 1980; Hardy 1989). To produce optimal repair tissue, all phases of this process need to be compleLed at the appropriate time.
Inflammation In response to tissue d amage a host of inflammatory cells wilh
specialist functions are released and attracted to the damaged area. There is increa sed local blood supply, leaking of plasma proteins and leukocytes from the blood vessels and accumulation of white ,
cells at the site of the inj u ry (Enwemeka 1989; Evans 1980) These cells wlll be involved in the clearance of dead and dying cells and any foreign matter prior to the re-growth of new vascular channels and nerves into the damaged area. The cardinal signs of inflammation,
heat, redness, pain, swell i ng and lack of function may be displayed (Evans 1980) and are a result of the inflammatory exudate. The swelling, heat and redness are products of the vascular aCLivity; the pain results from the presence of noxious inflammatory chemicals and heightened mechanical sensitivity Another sign 0 f in [lammation is increased tissue sensitivi.ty to ordinary me c h anical stimuli; this will be discussed in the next chapter In optimum conditions the inflammatory stage lasts less than five
days, with a gradual reduction of inflammatory cel ls lhereafter and
none present at the end of the third week (Enwemeka 1989) In this period a mesh of fibrin forms from the protein fibrinogen in the inflammatory exudate and seals the injury During this time the application of ice, co mp ression
,
elevatIOn and gentle muscle
movements are indicated to reduce the inflammatory exudate (Evans
1980) The greater the amount of exudate, the more hbrin will be formed and the more inextensible will be the rep a ir Ice, if a pp lied in the first few days follOWing injury, can reduce pain and oedema lee is of little value after the fifth day as the inflammatory cells are replaced by fibroblasts. These soon begin to lay down fibrils of collagen
Tissue repair The fibroplastiC or repair stage thus commences as the acute infla mmator y stage subsides and lasts about three weeks (Enwemeka 1989). It is during lhis phase that the collagen and
CHAPTER
SOFT TISSUE PROPERTIES
glycosaminoglycans that will replace the dead and damaged tissue are laic! dow n There is cel lula r proliCeration, which results in a rapid .
increase in the amount of collagen, and damage d nerve endings and capillaries 'sprout' and infiltrate the area
(Cousins 1994).
The cellular
activity is stimulated by the physical stresses to the tissue. With inactivity, c ollagen turnover occurs and new collagen is made, but it 1S not oriented according to stress lines At the end of this phase
hbrous repair should be established and collagen mass is maximal, but the tensile strength of the new tissue is only 15% of normal CHardy 1989) To encourage good quali ty repair with collagen fibres orien ted according to stress lines, gentl e natural tension should be applied to recen t injuries, commen c ing at about the fifth day (Evans 1980) Gentle te nsion applied early in the heal ing process will promote greater tensile strength in the long term. From the first w e ek a progressive increase in movement should be encouraged so that full range is possible by the third or fourth week It
is within this p eriod that appropriate education and movement proVides the op timal climate for uncomplicated re p ai r An experimental animal model showed that .
the application Ol stress during this repair phase was able [0 change the length of scar tissue, and thus remodel it according to function
The
same stresses applied to scar tissue that was three months old
had little effect on its length (Arem an d Madden 1976) It should be nOled, however, that at this stage if an over-enthusiastic approach to treatment is adopted, the repair process can be delayed or disrupted and the presence of innam matory chemical irritants
and exu d ate will be p rolonged or re-stimulated. During this early stage of he a ling movements should be just into stiffness and pain ,
and entirely under the patien t s control. Any discomfort provoked '
by the movement should abate as soon as the movement is released. If lasting pain is p rovoked it is likely that re-inJury has occurred, the innammatory phase has been re tri ggered and resolution of the -
problem will be funher delayed
.
Remodelling Wound repair is only optimal if remodelling of the scar tissue occurs. This involves increasing s trength and fl exibility of the s car tissue through progreSSively increased normal usage and specific loading Remodelling is the process of turnmg weak, 1mmature and disorganised scar tissue into a functional structure able to perform
Two
123
241 CHAPTER Tvvo
THE
HUMAN I XTREMITIES: MECHANICAL DIAGNOSIS & THERAI'V
normal tasks. The repair is unlikely to achieve the s t re ngth of t he original tissue, but progre ssive loading and mechanical sti m ulation enhances the tensile strength and improves the quality of the re p air
.
This occurs over several months after the original in] ury. Tensi Ie strength is increased by stabilisation of the fibres through cross linking, alignment of the fibres along the lines of stress and synthesis of type I collagen (Barlow and Willoughby 1992; Witte
and Ba rb ul 1997) Several factors can promote a less than optimal repair The granulation tissue, which repaired the damage, can now act as glue to prevent movement between tissue interfaces. During the period when collagen turnover is accelerated, there is also increased molecular cross-linkage - these processes may produce adhesion fo rm ati o n and impair collagen gliding (Hunter 1994; Donatelli and Owens-Bu rkhart 1981) Newly synthesised collagen will tend to con tract after three weeks; this naturally occurnng s hrinkage is said to continue for at least six
m ont hs if nOl fo rever (Evans 1980) Thus recently formed scar tissue ,
will commence shortening unless it is repeatedly stretched The
stretching process should be commenced in the early stages following" injury and continued until well after full recovery so no soft tissue shortening is likely to develop. Low-load regular application of stress
will also help to increase the tensile str ength of the repair tissue (Hardy
1989) Failure to perform the appropriate tissue loading will leave the repair process complete, but the remodelling stage incomplete; the indiVIdual may still be b othered by pain and limited [unction, and the tissue will remain weak and prone to re-injury The ner v e s
,
which infiltrated t he tissue d u r ing repair, can now be sources of pain each time the scar is stretched or loaded. This is a common cause of persistent symptoms in many patients. The regular application of intermittent stress or loa din g to bone and normal soft t issu e enhances structural integrity through the process of remodelling During the healing process loading for prolonged periods must be avoided as this may disrupt the repair process. Prolonged stress damages; intermittent stress strengthens Thus the p r oper rehabilitation of tissue damage involves progressive, incremental loading and act i v i ty in order to r es tor e the SLructure to full function and to restore the pacient's confidence to use it This is t h e essential ma nageme nt strategy during the repair and re m o d elli n g stages
CHAPTER
SOFT TISSUE PROI'ERTIES
In summary, no inlury ca n be made to heal faster than its natural rale; whenever the r e has been tis sue damage the processes of
i n fl a m m a ti on repa ir and remodelling h a ve to occur to allow full ,
resto ra ti o n of n o rm a l function. "Failure oj any oj these processes may result in inadequate or ineffectLwl repair leading to either chronic pathological changes in the tissLle or to repeated structural fail u re
(Barlow a n d Willoughby 1992)
"
T h e se processes are essentially the
same in te n d on s, muscles, lig a m e n ts and a ll soft tissues; however,
i n trins ic ["actors may be te n do n
m o re likely to im p ai r the
recovery process in
injuries, especially if the onset is through overuse rather than
trauma (8m"low and Willoughby
1992) Early progressiv e active
rehabilitation is essential to optimise repair and function. No passive
modality used within physiotherapy has yet been sho \VTI Lo reduce the t i m e for the completion of natural healing. We can avo i d delay to
the heali ng process and ensure t h at the climate for re p air is fav ourable (Evans 1980) Strenuous mechanical therapy applied when the pain
from the injury is essentially c h e m i c al will delay reco v er y The integrity of the repair must be established before more v igorous procedures are applied. H ow e v e r of equal importance is the use of a ,
"progressive,
c
o n tr o l le d programme of load i ng the tissues at the
a pprop r ia te time d ur i n g the rep ai r process in ord er to promoLe a fully func t io n a l structure which the p a tien t is confident to use. Those [actors that may I"esrricr a return to normal funcnon are listed in
more detaillatel" Table 2.1
Matching the stage
Injury &:
}1
InOammation
Rep,
& ",,",,"
of
condition to
the
Protect from
management
further damage.
Prevent excessive inOammatory exudate.
Reduce
swelling
�
Gentle nalural tension and loading. Progressive reLUrn to normal loads ancl tension.
Remoclelling
Prevent
contractu res.
Normalloacling anclrension to increase strength
and
flexibiltty
Two
125
261 CHMIIR Two
THE HUMAN
EXTREMITIES: MECHANICAL DIAGNOSIS & THERMY
Failure to remodel repair tissue Following tissue damage an important factor in the physiology 01repair is the phenomenon of contracture of connective tissues. A characteristic of collagen repair is that it will contract over time. Recently formed scar tissue will always shorten unless it is repealedly stretched, this contracture occurring from the third week to the sixth
month after the beginning ol the inflammation stage Contracture of old scar tissue may in fact occur lor years after the problem originated ( Evans 1980; Hunter 1994) Cross-linkage between newly synthesised collagen fibres at the time of repair can prevent full movemel1l. Nerve endings infiltrate this area during the repair process and can makc the scar tissue a sensitised nodule of abnormal tissue (Cousins 1994)
Time course of cellular activity following tissue injury
Figure 2,1 30
____
cells
dying
� I
??V> U U
\
11
\
r I
V
I-r-:-.....
- - - lurl
Age
.
e\cC+C \ 6:<X:\ ." h�\� ·
. . .
S t res s es
.
. . . 59w:a.\h�
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...... . .
Continued use ma k e s the pain Yes
Or no apparent reason
::rc., lld.e.C C\,C\"t.:::L-
.
Constant symptoms
Pain at rest
Im provin g (unChangi� Worsening
o rse
No
Effect
I ) ,tte.:c::l0D\d::;,\D�. . �.C�
�b��.
Treatment this episode
00;:·C .
Previous episodes Previous treatment Spinal history
.�...
Medications: tried
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Paraesthesia
Present medication
Effecl
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Summary:
Acute 1 Sub-acute
Sites for physical examination
��
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ro
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Insidious onset
_
-
..
Yes 1 No
CHAPTER
COMMON DISORDERS
TEN
R_,cp'l:. ::::�u\:::\ec..
PERIPHERAL
DM,D,
Observation
�,
Active movement Loss
t\el'-...ICO
. .... ... &"
El'c:Yd\...\.Ccnc:.(� . . , u.\\ �� t::le'0,r-.c\ �x -
Passive movement Loss ( +I-over-pressure)
ERP.
,900
W" , ,qOo
. '" \
...... .. , .. , ..
ER P
PDM.
\o\EC5\CC�e
p(t::x:iLl ce:" . . ...... r:"C Better
Effect of repeated tests on movement:
decreases,
worse,
�c-duCf''''''::'' ..
Qb d u.ch CC':\
F�oc,�
.
produces,
repeated lests on pain:
l(X:)
. , . ,
�
Static Positioning Effects
Loaded I Unloaded
SPINE Movement loss .
Effect of repeated movements: .
Effect of static positioning:
Spine testing o o o N
eb\cxj. 'c5i'::-\cj: W h a t stops or r e d u c e s . " . ce:::A .
P a i n at rest
I n term i tt e n t symptoms
�
� t '::::'
�
.
.d::x::) u IOe.C
e.c ::\" �·�,
�
... .......
. D::'"J B\D,. .
. � .. .
.
..
. . . . . . . ,:';)I\'C)\ .l8.C
Acute
EHect . "
: oC",,:AC\e.::::>\ C':::'
(SU b·acute P C h ro n i c
c.\.. . .\\ c:\e:c . . .
..
3 y:e..\2'l.C ;::, . . BC.� '- )
.
.
. . . ,C'C ,0C.
S i t e s for phy s ic a l examination . . . . . , .
.p::CA:::>\er:-o
ph:'jS,O:\\:.f:e qJ,,... \
............ ,"
.
Trau m a .
Paraes t h e s i a
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ei"j
i d i OUS o n s
Yes
I
No
1 21 1
212
[ C H A rT E R T E N
T H E H U M A N E XT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E R A PY
Observation Active m ovem e n t
LOS�:;�� '-)Pi��
radiates, . ..
"
rc:, \"c\ c� p'C'?>"---'
.. . POM.
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9(:'�'0 4
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t ma g i n g
Summary: Sites for
.
. .
.
ph ys ical
Acute I
S u b- a c u t e
examination . . .
. . kree
·
�
Tra u m a
leSidi O US
onset
••• ·.• ��\\�.�· . ���\ ·d���t .• •
-:J ··
Yes
�
1 253
254 1 CHAPllR T E N
TH E
H U M A N E xT R E M I T I E S :
M ECHAN ICAL
D I AG N O S I S
& T H E RA P Y
. \'S� . D BJ::) .
PERIPH ERAL Observation
... PO M... . .... ...... E R P . . . . t\cee . . . .�. . . . . . . Y\eX.\OC\ /.E:.. x..\.e.0.6\ DO . . . . . . . . . .. . 0,\ . . . \OS.-:=:, . . . . . . .�� . . . ::-: .. . �\�5). c:B\?) . �I.A&dS , . . �\ . \b,\�
Active movement Loss . .
Passive movement Loss . ( +I-over-p res s u re)
K\ee � &x , .. .
Resisted
E;�\ t
. C'O . �D
.'t\\n�
no b e tt e r,
no w o r s e ,
no effect
·
.
��. \Q�
· · · · · ·
�
Wo rse
Better
ua� \'�xlc:o
decreas e s ,
worse,
better,
. . p\Crl t
\ce:::r ::'
oc::.
.
.
...... POM
R . c : .\0 .
D\\ \��
SPINE Movement Loss
E ffect o f repeated move m e n t s :
Effect of
static
position i n g :
S p i n e tes t i n g : o o o
'" '" c
.9 ;;;
�
R e l evant I Sec o n d ary
t
CON C L U S I O N Dysfu nction :
(No releva0 Efai"J �
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·
�
'" N c '" '"
�
., 1:: f-
@
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·
p&0S P i n e
. .
C o n trac t i l e
A rt i c u l a r .
Postu r a l .
D e ran ge m e n t
� �... � ·
·
problem
.
U n c e rt a i n
PLAN
Exercise
Freque ncy
.. .5..\"". R/r£\ID.\. :-:. :=:SLl.a\5/. \.Ycc...e/ .::>� � �s . � . .� . \Q . . . . f'\\...SD ,� . . � 6U6-:\&\� . �� . �� .. . . . .. . ..
..
.
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.
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.... .
.
C H A PTE R
COM M O N D I SO R D E RS
Degenerative joint conditions I osteoarthritis The preva lence o f osteoart hritis increases l inearly with age from ab out 3 0 , b e fo re whi ch the d i sease hardly e x i s t s , with the ave rage age of onset b e i ng 5 5 . Be fo re 50 me n are a ffe c ted more th a n wome n , but a ft e r t h is age t h e p re v a l ence i n women is t w o or three times greater than m e n (Felson and Zhang 1 9 9 8 ; McCarthy e t al. 1 9 94) Symptoms
a re varied - pai n , achi n g , sw e l li n g , bony tend e rness and en largement ,
acti v i t y - re l a t e d p a i n , m o r n i n g a n d inactivity stiffnes s , c repi tus a n d pai n [u l l i m i t a t i o n o f movements (Oliveria e t al. 1 9 9 5 ; Huskisson and Hart 1 9 8 7 ; A l t m a n e t al. 1 9 8 6 ) The p resence of osteoarthritis (OA) is c o nfi r m e d by radiogra p h y ; h o wever, l a rge numb e rs o f ind i vi d u a l s w i t h t he rad i ograp h i c changes o f OA d o not have symptoms . V i s ib l e c ha n ges on x-ray increase with age a n d a re a l m o s t u n iversal a ft e r 5 5 , b u t i t i s estimated that only ab o u t 50% o f i n d i v i d u als wi t h these c h a n ges h a v e s y m p t o m s ( Hu skisson a n d Hart 1 9 8 7 )
For
i ns t a n c e , whereas 8 0 - 9 0 % of the popul a tion ove r 70 have rad i ogra p h ic changes i n t h e hands , o nly 9 % o f m a l e s and 2 6 % o f females have p a in (Petersson 1 9 96) Radiogra phic knee O A was found in 2 0 % o f a l a rge p o p u la tion su rvey, while only 5 % h a d these changes
and knee p a i n at the time of the survey (Claessens et al. 1 9 90) . Pai n ful knees accompanied by x - ra y changes occur in 6% of a d u l ts over 3 0 , wh i l e radio graphiC c hanges are fou nd in a b o u t 1 4 - 3 0 % o f those over 4 5 (FeLson and Zhang 1 9 9 8 ; Petersso n 1 9 9 6)
Symptoma tic
hip OA o c c u rs in 0 . 7 - 4 . 4 % of a d u l ts , while a b o u t 20 - 3 0 % o f w h i te E u r o p e a n s o v e r 5 5 d i s p l a y r a d i o gr a p h i c h i p O A - t h e p re v a l e n c e i s m u c h l ower (l - 3 % ) i n n o n - Caucasian p o p u l a t i ons (Felson 1 9 8 8 ; F e L s o n and Zhang 1 9 98) M o s t s t u d ie s s h o w t h a t the p ro p o rtion o f ra d i o l o gi c a l d isease tha t is sym p t o m a t i c is betwe e n 4 0 and 8 0 % . This d epends partly upon the seve r i t y of t he s igns and the site - severely d a m aged j o in t s a re more likely t o
be
p a i n fu l than m i l d change s , knees a n d hands a re mo re
l i kely to be p a i n ful than h i p s . Many peo ple with signs of OA do n o t h a v e p a i n o r have episo d ic o r intermittent pain ; many wi th o u t signs of OA can have p a i n fu l J o i n t s . The key message to p a t ients is t h a t radiographlc e v i d ence o f j oi n t changes d o e s not correlate c l osely wi th symptoms ( H o c h b e rg et al. 1 9 8 9 ; Spector a n d H a r t 1 9 9 2 ; Dieppe 1 9 8 9 ; Forman e t al. 1 9 8 3 ; Acheson 1 9 8 2 ) M y t h s ab o u n d c o ncerni n g O A , o n e o f w h i c h i s the i n h e re n t l y p rogressive nature o f t h e d isease
In fa c t not a l l p a tients p rogress
TEN
1 255
256 / C H A PTE R T E N
TH E
H U M A N E X T R E M I T I E S : M EC H A N I Ci\L D I A G N O S I S & TH U(A I'Y
r a d i o gr a p h i c a l ly o r s y m p t o m a t i c a l l y, a l t h o u g h m a n y d o . I n a s u b s t a n t i a l pro po r t i o n of those w i t h con fi rmed OA the sym p L ams either ge t no worse or ac tua l l y improve ove r t i me ( H o c h b e rg
1 996)
Seve ral s t u dies have fo llowed up p a ti e n ts w i th knee OA for a b ou t a decade or more . I n o ne study t w e n t y paLients with OA knee go t worse , seve n re m a i n e d the s a m e a nd fou r gOl be tte r ( M ass a rd o et a l .
1 989)
I n a l ong- term study, 5 7 % o f p a t ie n t s reponed a worsening
o f symp toms , bu t 2 5 % w e re unc ha n ged and 1 8 % were i m p roved (Hernborg and N i lsson
1 9 7 7) In a n o t h e r stu d y
with a n e l even-ye a r
fo l l ow- u p , l e s s t ha n ha l f t h e p a t i e n t s s h o w e d a w o rs e n i n g o f r a d i o gra p hi c fin d ings , wh i l e ab o u t 1 0 % s ho w e d i m p ro v e m e n t .
Although ha l f tho ught their pain had worsene d , their v i s u a l a na l ogue pain scales were the same , and those re po rting knee p a in declined from 69% to 52% (Spector e t a 1 .
1 992) .
These a u t h o rs concl u d e d ,
" I t appears that the lo ng- term progn O S i s in
a
l a rge p rop o r t i o n of
pati ents w i t h os teoarthri tis i s good. Only a m i n o r i ty a re l i k e ly to p rogress rapidly and have a deteri o rati o n in th e i r knee sy mptom s . "
OA i s ne i th e r an i n evitable part of the agei ng p ro c ess nor necessar i l y progressive . While abo u t 5 0 % o f those o v e r 60 have sym p t o ms o f
OA, this proportion remains reasona b ly s t a b l e t h ro ugh the 7 0 s , 80s and 9 0s (Forma n et a 1 . The h a n d s
,
1 983)
fe e t , kne e s a n d hips are t he pe ri p h e ra l j o i n t s m o s t
commonly a ffe c t e d by d e genera tive change s . Ankles and shou l d e rs a re involved less freque n tly, and elb ows and w ri s t s on ly occasi o na ll y (Pe t e rsson
1996;
H u s k i ss o n and H a r t
1 9 8 7)
T h e c a u s e o f t h.is
p re d i l e c t i o n fo r c e r t a i n j o i nt s is u n k no w l1 . I t is c o m m o n for i n d ividuals La b e a ffected in several site s .
O A is ch a r a c t erise d by a reas o f local d e s t ru c t i o n o f t h e a rtic u l a r cartilage and re modelling o f the s u b c h o nd ra l bone I f the J oi n t damage is extensive enough these c h a nges are seen o n x - ra y as narro w i n g o f the j O int , s c l e rosis o f t h e b o ne a n d growth o f osteo phytes M u c h o f t h e pa t hol ogy o f OA i s s e e n as an a ttempt a t repair, o r an aberra n t version o f t he same . T he articu lar ca r ti la ge which i s the mai n targe t ,
tissue of OA , is devo i d of nerve endings whic h m a y explain the lack of pain in many p a t i e n ts , especia l ly those with o nly mild disease (McCarthy et a1.
1 99 4 ;
Hu skisson and Hart
1 987)
Pain is thought to a rise from t he subchond ra l b O l1e , p e r i o s te u m , synov1u m , ca psu le a nd liga m ents resulting fro m abnorma l mec h.anica l stresses o n the p e ri - a r ticular s t ru c tu re s . I n i t i a l l y t h e re is aching o f
COMMON
D I S C)lt D E RS
C H A rT E R TEN
j o ints at rest o ften re l i eved by m ovement . As the disorder d evelops pai n becomes re lated to use , being especi ally n o ticeable o n ini tiation o f move men t or weight-bearing. T here is fibrosis , thickening and contracture o f the ca psule causing s t i ffness , red uced movement a nd pain a t the end of range Restric ted venous o u t fl ow causing stasis and conge s t i o n can also be a fac t o r in pain p roduction. Abe rrant load i n g can cause e xcessi ve mechanical strain on ligaments , possibly lead ing to micro-trauma. At the more extreme end of the continuum of pathol ogical changes [·ragme n tation of t he ca rti lage or bone can lead to the formati on o f i n tra-arti c u l a r bodies that may cause mechanical o r in flamma tory symptoms d u e to nli tation o f t h e synoviu m . There may be episodes o f inflam mation d u e to syno v i tis , causing a constant chem ical pain . N o x i o u s slimu l i fro m d iseased j o i n ts can cause inhibition o f motor neurones l e a d ing to weakness and muscle atrophy Muscle weakness and d a mage to ligame n ts may i n d u c e u n s ta b l e j o ints t h a t a re vu l nerable t o trau m a , a n d thus prone to episodes o f acute inj u ry, inflammation a n d post-traumatic pain . Persistent p a in can lead to se nsitisa tion at local and cen tral l evels resulting in a l owering o f the pain th reshold (McCarthy
et
al. 1 99 4 ; Huskisson and H a rt 1 98 7 ;
Preid le r e t a t . 1 9 9 6 ; Akeson
et
al . 1 9 89 ; Thre l keld a n d Cu rrier 1 9 8 8 ;
Ma rks 1 99 2 ) T he cause o f s y m p t o m s from degenerative conditions is there fo re mu l t i faCloria l , a n d re prese n ts a spec tru m inv o l ving m e chanica l , i n f1am mato ry, isc haemic and other fac t o rs . I t i s suggested that O A is not in fact
a
s i ngl e disease , b u t is an um bre lla term for a range o f
similar con d i ti o n s w h ose aetiol ogy may b e primarily systemic or biomechan ical (Dieppe and Ki rwan 1 9 94) It is quite likely under these c i rcumstances t h a t d i fferent presen t a t i ons may respond to d i ffe rent manage ment stra tegies. Some pa tients having symptoms from OA may presen t with p u rely mechanical probl ems - for instance , end -ra n ge capsula r s tretc hing reveals limitation and pain . In other pa tients n o n - m ec h a n ic a l fac t o rs m a y be p a r a m o u n t . As i n all p e r s i s t e n t t i s s u e a b n o r m a l i t y t h e role of s e n s i t i s a t i o n a n d deconditioning fro m lack o f n ormal use shoul d b e co nsid e red . M a n agement of dege nerative j o i nt c o n d i t i o n s
M a n a g e me n t gU i d e l i n es fo r OA fre q u en t l y s t re s s the va l u e of educa tion a n d exerc ises (McCarthy
et
aL 1994; Dieppe 1 9 9 3 , 1 99 5 ;
H ochberg 1 9 9 5 a , 1 99 5 b) Exercise is the o n ly p hysical m o dality that
1 257
258 1 C H A PT E R T E N
T H E H U M A N E X T R E M I T I E S : M E CHA N I C A L D I A G N O S I S & TH E R A I'Y
has consistently been found to be valuable in the m a n a ge m e n t of OA (Clarke 1 9 9 9 ) . A ' p y ramid' a pp ro a c h to the m anagem e n t o f OA has b e e n p ro p o s e d , in w h i c h a l l p a t ie n ts s h o u l d h a ve a c c e ss to i n terve ntions at the base o f the pyramid , whe reas onl y the few with the severest symptom will need those at the apex (D ieppe 1 9 9 5 ; H ochberg 1 9 9 5 a , 1 9 9 5b) Management s t r at e g i e s t o b e used w i th t h e m a j o r i ty o f p a t i e n t s i n c l u d e e d u c a t i o n , c o u n s e l l i n g
,
empowe rmen t , exe rcise s , s ti.cks , physiothera py a n d ana l gesics . A mino rity o f p a t i ents may need NSAlDs , hydro therapy a n d mo re c omplex aids, while
a
few will need su rge ry (Dieppe 1 9 9 5 )
The therapeutic v a l u e o f N SAlDs f o r OA is not clea r cl esp ite their rou tme use . OA frequently has only a mi n o r i nOam m a t o ry co m p o n e n t
( D i e p pe et a l . 1 9 9 3 ) I e a p pears L h a L simple a na l gesics a re a s good a s .
N S A I D s (Towheed et al . 1 9 9 9 ; D i e p p e 1 9 9 3 ; M c C a rLhy e t a l . 1 994) Brad ley e t a l . ( 1 9 9 1 ) c o m par e d i bu p ro fen a t a n anti- i n fl a mmatory and p ure ly a na lgesic dosage , and acetami n o p hen ( p u re l y an a n a l ge s i c )
and fou n d tha t all three groups had imp ro v e me nts
i n maj or O U l c o m es
,
which were n o n - s ign i fi c a n t b e t w e e n the gro u p s . C o m p a riso n s between N SAlDs a n d place bos o r analgesics are co nsidera b l y less rese a rched tha n comparisons b e tween di f fe re n t NSAlDs.
It
wo u l d
appe ar that the d ru g com p a n ies are happier fun d i n g c o m p a ra t ive stu dies between di ffe rent N SA l Ds than c o m p ar ing t h e m to much less costly analges i cs , let alone non- p h a rmacologi c a l interventions (Dieppe et al. 1 9 9 3 ) n l e re is a ls o
co
n c e rn that the re is b i a s e d
i n t e rp retation o f resu lts in fa v o u r o f a c e rt a i n p ro d u c t in t r i a l s associa ted w i th drug manu facturers ( Ro c h on et a l . 1 9 9 4 ) NSAlDs a r e also as so c i a t e d with considerable mo rbi d i ty a n d mortal ity
d u e to gastrointes tinal d a m a ge . A m e ta - an a l y s i s c on c lu d e d tha t N SAID users a re three t i m e s more like ly to d e ve lop serious adverse gastrointestinal events than non-users ( G a b ri e l et a l . 1 9 9 1) It is estima ted that 20
-
3 0 % of all hospita l isations a n d deaths i n t he
ov er 65 s are d u e to p e p t i c u lcer disease attributa ble to N S A l D thera p y -
( H ochberg 1 9 9 5 a ; B a ko w s k y and Hanley 1 9 9 9 ) . l L is estimated t h a t there are ab out 2 0 0 deaths a ye ar J u st i n t he UK attrib u table to their
use (Somerville et al. 1 9 86) , and tha t t h ey acco u n t for 2 5 % o f all d rug side effects (Rochon et al. 1 9 94) Because o f the n u m b e rs of people using N SAlDs worldwide - 30 mil lion people are t h ought t o use them every day - adverse events a r i s i n g from the ir use a re more frequent than with any other fo rm o f d rug treatme n t (Gabrie l and Bombadier 1 99 0 ; Haslock 1 9 90) As a c o n se q u e n c e o f this d ebate it
C O M M O N D I S O R D E RS
C H A PT E R T E N
is s u ggested t hat d ru g s , o f ten o f the wron g s o r t , a re overused , whereas biomec h a n ical inte rventions for the management of OA are unde rused
( D i e pp e 1 9 9 3 ) A p o si t i v e a l t i t u d e t o w a rd s p a tients w i t h this c o n d i t i on is warran ted as s y m p toms o f t e n stabi l ise o r imp rove , and there is n o t ne c e ss a r il y an i n ev i ta b le progression w i th i ncreasing morb i d i t y and disability. Ano t h e r o f the my ths o f OA
-
thal c ar t i l age c a n n o t re pa ir i tself
-
is
d i s p ro ve d by c o n te m p o ra ry e v i d ence (Bland 1 9 9 3 ; M c C a rt hy et al. 1 9 9 4) It 1S importan t to try to ' d e - m e d i ca l is e ' th e c o n d i tion , reassure a b o u t t h e pro g n o s i s , and e nc o u r age c o n t rol and e m p o w e rment (Dieppe 1 9 95)
As in all c h r o n i c d i seases the p a t i e n t has certain
res p onsi bi l i t i e s
-
to l e a r n ab o u t the c on d i ti o n , t o ta k e c e r t a i n
re spo nsibi l i ti es , a n d eva luate t he heal t h care e xperien c e ( B r a dy 1 9 98) .
Cu r rent me t a - an a ly sis o f s t u di e s suggests tha t p a ti e n t edu cation fo r rh e u m a t o l o g ic a l c o n d i t i ons c a n a ffe ct k n ow le d ge , p a i n , J oint c o u n ts , d e p re SSi o n , e xercise a n d c o p ing behaviours , wi t h se l f- e ffi cacy and
s o c i a l s u p p ort a p pearing t o be s t ro n g causa l mechanisms for these
bene fi ts (Lo rish and
B o u t a gh 1 9 9 7 ) I nc r eas e d self-effica cy, which is
the pa t i e n t s s e nse o f ab i li ty to a ffe c t the c ons e q u e nc es o f d isease , '
i mpro ve o t he r o u tco m es such as pain and d i sa bi li. t y (L o r i g et al . 1 9 89) F o r instanc e , indi v i du a l ised progr a mme s i nv ol ving exercise , re l a xa t i o n , ap pro p ri a t e use o f a ffe cted j oi n ts a nd p roblem- s o l vi n g re s u l t e d i n better functional p res e rva t i on , imp ro ved pain , fewer health c a re v is i t s and l e ss d e pre ssion
( L o r i g and Holman 1 9 8 9 ; Lori g
et
al.
1 9 9 3 ; Mazzuca e t al . 1 9 9 7 ) The clini ci a n s role is obviously to o ffer '
info rm a t i o n abo u t t h e c o n d i tio n a n d sel f-management strategies tha t
will a f fe c t i ts consequences. A sy s te m a t i c re v i e w of non - i n va si v e s tu d i e s into t h e rapies fo r OA o f t he h i p and knee fo und that exercise re d u ces pain and i m p roves fu n c t i o n in p a t i e n ts w i t h knee OA, but genera l ly fai l e d to su p p o r t p a s s i v e tre a tm e n t m o d a li ties . N o s t u d i e s were fo un d b y t h i s group that evaluated exe rcise for OA of th e hip. Of th e 600 artic l e s they i n i t i a l l y review e d o v e r 60% re lated t o tr e a t me nt by NSAl D s , whi l e
only 5 % l o o k e d a t non-m e d i cal eva l u a t i ons (Puett and Gri ffi n 1 9 94) .
S i n c e t h e n a u i a l c o m p a rin g m e d i c a tio n and e d u c a ti on with o r wi tho m su p p l e ment ary
e x e rcis es
for OA hips a n d knees foun d tha t
the exe rcise group , a ft er twelve weeks , had gre a t e r i m p r o vem e n t s in r e d u c t i o n of p a i n a n d d i s ab i l i t y ( v an B a a r e t a l . 1 9 9 8 b )
H ome
exe rci ses fo r the h i p a re as e ffe ctive as o u tpali en t hy d ro th e ra py ( G ree n
1 259
260
I C H A PT E R T E N
TH E
H UMAN
E X T R E M I T I E S : M E C H A N I CA L D I AG N O S I S & T I- H RA rY
et a l . 1 9 9 3 ) A n o th e r w i d e - rangi ng re view a l s o found li t tl e e v i d ence i n fa vou r o f p a ssi v e tre a tment modali t ies , but c o n s i s t e n t v a l u e in s trengt h e n i n g e x e rc is es fo r the knee (Clarke 1 99 9 ) An example is a su pe r v i se d fi tness walking and e d u ca t i o n p rogra mme t ha t i m p roved
fu nctio nal s t a tu s and pain , and re d u c e cl me d ica t i o n use c o m p ared to a contro l grou p (Kov a r et aL 1 9 9 2 )
Part i c i pa t i o n in e i t he r a n
a e rob i c o r resi s t a n ce exe rcises p ro g r a m m e b r o u g h t a b o u t i m p rovements i n m e a s u res o f disa b il i t y, physical pe r ro r m an ce and
pain compared to an e d u ca tion progra m m e ( E t ti nge r
et
al. 1 9 9 7)
Main t a i n i ng a fu ll ra n g e o f m ov e m e n t a n d musc l e strength a L a n a ffe c t e d J o i n t m a y re d u c e disease p ro greS S i o n a s w e l l a s g r e a t l y decreaSing p a i n and disabili ty ( D i e p p e 1 9 9 5 ; M cCa rt hy et a l . 1 9 9 4 : Fisher e t al . 1 9 9 1) S e l f- m a n a g e m e n t exercises
Patients with degenera tive J o i n t cond itions may present with restric t e d m o vements w i t h p a in a t t he end o f r a n ge . T h is i s d u e t o capsu l a r thicke n i n g a n d contracture o f t h e J o i n t ca psule ( M c C a r t h y e t a l .
1 9 94) This contra c tion and loss o f e lastic i t y causes d y s functi o n , a n d i n m a ny cases even sma l l i mprovement i n the ran ge o f mot i o n
c a n resu l t i n reduction o f pain I m pro v e m e n ts a re e s p e c i a l l y p ossible w h e n the e n d - range fee l s p lastic rath e r than l i k e c o n c re t e .
I
Photos 1 04.
1 05
Different metbods of se!fmob ilisation into knee extension, with or witho u t oue,pressure. Pressure on, pressure off, t e n limes.
1 05
1 04
C O M M O N D I S O R D E R.S
C i-IA I'T E R T E N
Photos l Ou, 1 0 7, l OR Differell/ me/bods of setlmobilisatio n into bip flexion with overpressu re. Pressure O l l) pressure o.h: leJl tirnes.
106
1 08
/1) 7
Th ese p ro b l e m s a re m o s t c o m m o n l y seen
in patients
wi th k n e e a n d
h i p O A In h i p O A d iffe re n t p a t t e rns o f radiol ogica l a n d p a t h o lo gical c h a nges have b e e n observed (Cam e ron and Macnab 1 9 7 5 )
They
rou n d Lhal 40% of p a t ients had early and marked capsular restricti on , w h i l e in L h e re s t capsu lar re s t liction was m i n i m a l unti l th e re were
g ro ss d e genera tive change s . It is sugges ted t h a t the capsu lar c hanges a re sign i fi c a n t i n th e p rog re ss i o n 0 1- the c o n d i tion (Camero n and M a cnab 1 9 7 5 ) At t he knee p a t ients mus t be enc o u raged to regain and m a i nta i n e x t e ns i o n , hype rextens i o n a n d Hexio n . A t the hip the key m ov e m e nLS a re aga i n flexion and e x tens i o n but a l so ful l range ,
of m e d ia l ro t a L i o n a n d a b du c t i on are c ommonly l o s t (Dieppe 1 9 9 5 ) Se l f- m a nage m e n t exerc i ses can be s u p p l e m e n te d by a s h o rt c o u rse of c l i n i c i a n m o bi l is a t ions , w it h media l r o t a t io n at the hip sometimes
being d i ffi c u l t for the p a t i e n t to do ade q u a tely l n d i v idual pat ients
1 261
1
262 C H A rT E R
TEN
TH E
1 09
H U M A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T i l E R-MY
111 Photos 1 09, 1 1 0,
11I
Differe n t methods oJ self l l lO iJilisCI /iol1 illto h ip extension u 'itb ouerpressure, bilateral II l I d u n ila t e m /.
Pressure on,
pressure
off
fen lillles.
/ /0
Pho to 1 1 2 111 /"rnol ro tation oj the hip, with ur witho ut o l 'erpressure. Pressure on, pressure oJf, ten times.
present w i th va ri a ti o ns o f m o ve me n t l o ss and the p a r t ic u l a r m o v e m e n t s t h a t must be p r a c t ised s hould b e d e c i d e d b y phys i c a l examina llon ra the r than t h e o re t ica l p resc r i p t i o n P a t i e n ts w ill need to do the exe rc i ses w i t h over p re ss u re s e v e r a l t i m e s daily u n t i l i mp roved m o bil i t y p ro d u ces a n i m p rovement i n s y m p t o ms Afte r t h i s , e x e rc i s e s s h o u l d be d o ne o n a daily basis LO mainta i n the c h ange The previo us ana lysis o f the evidence makes it c le a r t h a t a ge neral strengthe ning o r exercise p rogra m m e is a v i tal pa rt o f the ongoing sel f-management of this c o n d i t i on A l l patients sho u l d be a d v i s e d o n t h e v a l u e o f p e d o r m i n g s u c h
a
p rogramm e , and c l i n i c i a n s s h o u l d advise and d iscuss w i t h pa tients the pra c t i c a l i t i e s a n d p ro b l e ms o f s o d o i n g .
/ /2
'
C OJI/\ Iv\ O N
D I S O rW E R S
C H A rT E R T E N
Assess m e n t
Fi g u re 1 0 . 6
sheet - hip j oint
OA
TH E M c K E N Z I E I N STITUTE P E R I P H E R A L A S S E SS M E N T
.I . .
. . . . . . .I . .
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from present
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.
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of .
S y m p to ms at o n s et I n t e rm ittent s y m ptoms
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worsens \)�
S u m m a ry :
�C..r �iO J "'bO 0 d;�� ,
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tried c\-� \ D. . .
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n o better,
. . . . . . . OOt
. podu ced
.
. 1X::l .t
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.
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:;'\
elUeD ;::- c::f':\
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)
�� /
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� �\ \ d.\nc�. . . U::X:X" .seD5 . . .0CD.c. ��b' , . 'c:::e.&c \� . . IT'C Ce\X"f'ru.s . . . "" . . p'&.\O�L\\. t . . . . raT . . . lLQc::::,EDe.o . C o n s t a n t symptoms
W h a t stops or
I nt e rm i ttent
reduces .
I
Pu"\'"
. . . . . . . . .Ce-�t .
Better
C o n t i n u ed u s e m a k es t h e p a i n P a i n at rest
eYeS
Dist u rbed n i g h t
/
Yes
Other q u e s t i o n s . . .
Trea t m e n t t h i s e p i s o d e P revi o u s episodes
. . .
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CS . �cl:\Ge. �>r�
. . . . . . . . . X . . \0 . . . .
.
>SCl1lbly line workers. J Kand Surg 20B.782-790. Cail1et R (19813). Neck and Arm Pain (2""ed) FA. Davis, Philadelphia.
Cail l et R (1981b) Shoulder Pain (2n"ed) FA. Davis, Philadelphia. Cameron HU, Macnab I (1975) Observiltions on OA of the hlp Joint Clin Onh & Rei Res 108.31-40. Carrico IJ, Mehrhof A1, Cohen IK (1984) B i ology o[woLlncl healing Surg Clinics
Nth Am 64.721-733. Chakravarty KK, Webley M (1990) Disorders of the shoulder :
Ciluse of disability in elderly people. Chard MD, Ca wsto n
IE,
an
olten unrecognised
BMJ 300.848-849.
R i l ey GP, Gresham GA, i--i8zleman BL (1994). Rotator cuff
degenerat ion and lat e ra l epicondylitis: a comparative his tologi cal study. Ann
Rheum Dis 53.30-34. Chard MD, H azle man BL (1987). Shoulder disorders
In
the elderly (a hospital
study). Ann Rheum Dis 46. 684-687. Chard MD, Hazleman R, Hazleman BL, King RH, Reiss BB (19 91)
Shoulder
disorders in the elderly (3 community study). Arthr &: Rheum 34. 766-769. Chard MD, Sallelle LM, Hazlem3n BL (19 8 8) The long-term outc o me of rotator cuff tendonitis - A review study Br J Rheum 27.385-389. Charles C, Gafni A, Whelan I (19 97).
Shared
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44.681-692. Cherkin D, Deyo RA, Berg AO (19 91)
Evaluation of
a
phy sici a n education
intervention to imp ro ve primary care fo r low back pain. 2. Impact on patients. Spine 16.1173-1178.
Cherkin DC, MacCormack FA (1989) Patient evaluations of low back pain care
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THE i-iuMAN EXTREMITIES: MECHI\NICAL DIAGNOSIS & THERAPY
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