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The patient-centred approach to dealing with movement disorders
This key component is...
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.llllfollnate wording .
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The patient-centred approach to dealing with movement disorders
This key component is based around a personal com mitment to the patient. In the context of the Maitland Concept a personal commitment means: •
developing a level of concentration such that the manipulative phYSiotherapist feels mentally and physically challenged throughout each episode of care: take for example the Test cricketer who makes a Test Match century and is at the crease for several hours. A high level of concentration is needed to enable his shot selection to be accurate throughout his innings. Likewise the physiotherapist who is with a patient must see each piece of information as 'a good length ball' and think how to reply or ask
a relevant follow-up question, carry out another examination procedure, or select an appropriate treat ment technique in order to build a problem solving innings each time the patient is seen (Fig. 1 .2) •
•
•
being prepared to revisit, time and time again, the patient's sensory, cognitive and emotional world until the information that the patient provides makes sense being totally non-judgemental at all times, actively listening to the patient and believing that every thing the physiotherapist is told is true developing a skilled understanding of verbal and non-verbal communication and being prepared to critically appraise one's own communication skills;
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MAITLAND'S PERIPHERAL MANIPULATION
[ the physiotherapist should always shoulder the blame for errors in communication •
using the patient's own terminology (the physio therapist should adapt to the patient rather than continuously expecting the patient to adapt to the clinician)
•
•
•
endeavouring to understand the 'frame of refer ence' from which the patient expresses the effects of the disorder knowing what the clinician should know creating an interpersonal environment in which the patient feels comfortable, confident and trusting in the clinician.
The brick wall approach and the primacy of clinical evidence
Figure 1 .2 Australian Test Cricket Captain Steve Waugh (1999-2003) who scored over 1 0 600 Test runs including 32 Test centuries. Reproduced by kind permission from The Wisden Cricketer(January 2004) and from Steve Waugh. © Patrick Eagar (photographer).
The brick wall approach to clinical decision making applies to all aspects of this manipulative physio therapy model. The manipulative physiotherapist is encouraged to decide which side of the brick wall is being considered during each stage of decision mak ing. The decision-making process of the Maitland Concept is primarily on the clinical evidence side of the brick wall although diagnostic/theoretical consid erations will influence the exact nature and dosage of the intervention. Therefore the primacy of clinical evi dence is a major part of the Maitland Concept. For example, the prime concern of a patient with a diagno sis of tennis elbow will be that the problem resolves and does not recur (history), that the pain being experi enced will go away (symptoms) and that grip strength when lifting things will return to normal (signs). Figure 1 .3 is a dynamic representation of the use of the brick wall for clinical decision making. At the heart of the Maitland Concept is a special mode of thinking in two interdependent compartments separated by a symbolic permeable brick wall, thus allowing for hypotheses and speculations. The separ ation into 'theoretical compartment' and 'clinical com partment' in the clinician's mind prevents thoughts relating to the theory of a disorder overriding the Figure 1.3 The symbolic permeable 'brick wall'. . - Elbow pain and soreness since decorating
Symptoms - Sharp pain on the outside
of the elbow when gripping - Reduced grip strength
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painful and stiff elbow extension/adductions
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The Maitland Concept - an introduction
clinician's decision-making processes and does not inhibit the clinician from discovering the patient's dis order in terms of its history, its symptoms and its signs in fine detail. It also allows for safe and effective man agement of disorders where there is an incomplete or uncertain diagnosis. The paradigm of identifying and maximizing movement potential
The World Congress of Physical Therapy (WCPT 1999) in an updated description 'recognizes that physiother apy is concerned with identifying and maximizing movement potential within the spheres of promotion, prevention, treatment and rehabilitation'. The Maitland Concept, with attention to detail in the analysis of quantity and quality of human movement and with mobilization/manipulation techniques designed to restore movements to their pain-free ideal state, is well placed to contribute to the realization of such a paradigm.
Examination An essential requirement is believing that a patient can have: • • •
more than one kind of pain different pains in overlapping areas different pains with different behaviours and histories.
It is also important to believe that there are fine details of information which the body can tell the patient and that the clinician cannot know about unless the patient is encouraged to talk about these trivia, thereby encour aging a personal and total commitment to the patient. In the physical examination, aspects which are emphasized within the Maitland Concept are: •
•
• •
• •
•
functional movements which the patient can perform to demonstrate the pain or other symptoms for which treatment is being sought re-enacting the injuring movement when the disorder has been caused by some traumas differentiation tests pain response to accessory movements performed in loose-packed positions and at the end of range of physiological movements pain response to 'combined movement' tests pain response to the testing of 'functional corners' pain response to movement, both physiological and accessory, performed while the joint surfaces are held compressed together
•
•
•
test movements requiring overpressure to establish . normality not thinking of range of movement without relating the pain response to it and vice versa movement diagrams for the purpose of learning and teaching.
Mobilization/manipulation techniques Although it is necessary to have a basic set of techniques from which to teach, the clinician must be totally open minded and capable of adapting and modifying tech niques to achieve the purposes for which £hey were cho sen in relation to movement and pain. A technique is the brainchild of ingenuity. For example, a patient may experience pain at the front of the knee when going up stairs. A possible treatment technique may be tibiofemoral joint passive accessory movement in the weight-bearing position, thus reproducing the pain, the desired effect being to enable the patient, subsequently, to go up stairs without any symptoms (Fig. 1.4). Grades of passive movement and rhythms are used for teaching, communication between clinicians, recording purposes and to allow the clinician to think in finer detail about the technique. Two styles of tech nique are specific to the Concept: •
•
Performing a movement in an oscillatory manner within a range of movement where there is no stiffness, muscle spasm or pain. Using compression as a component of a treatment technique.
Figure 1.4 bearing.
Tibiofemoral accessory movement in weight
5
MAITLAND'S PERIPHERAL MANIPULATION
Recording of treatment must be complete and in depth, yet brief.
approach to dealing with patients who suffer from dis orders of their movement system (Sahrmann 2001).
The science and art of assessment
The central core
Repeated assessment and ongoing analytical assess ment are the means of evaluating and reflecting on everything done during the clinical decision-making process. Assessment is the epitome of the Concept. Clinical proof of whether treatment is working or not is achieved by continually comparing the effects of the selected treatment forms on the patient's symptoms and signs. At the same time hypotheses about the cause of the problem, the structures at fault, the pathobiological mechanisms involved, expectations for recovery and appropriate management strategies can be confirmed, discarded or re-ranked. Therefore this process of evaluation involves the clinical science of measurable change and the art of decision making about treatment, often based on clinical experience and intuition. Assessment is used at the initial consultation in a manner which determines the effects of the disorder on the patient as a person and to identify relevant movement impairments and consequent activity limi tations. The second application of assessment is in clin ically proving the value of treatment techniques by repeated, detailed assessment and re-assessment of the patient's symptoms and signs. Analytical assessment is used throughout the episode of care. Such assessment must be made in light of the fact that the body has an enormous capacity to compensate for injury, disease or congenital abnormalities. The body also has the capacity to inform the patient of seemingly trivial details which the clinician must encourage the patient to report so that assessment can be more informed and accurate.
The central core or theme of the Concept is a positive personal commitment to understand what the person (patient) is enduring. Therefore the Maitland Concept is a patient-driven model. It is inclusive and places the patient and their main probLems at the centre of every thing the manipulative physiotherapist will do or say. The body's capacity to give information about how the patient is affected by these problems (symptoms, activ ity limitations, etc.) is the key to the planning, selection and progression of manipulative physiotherapy inter vention. For example, if a patient is unable to put his socks on in the mornings because of pain and stiffness in his groin, the prime aim should be to use this func tional loss in examination and assessment to discover the source and cause of the symptoms and treat them in a way that allows the patient to put his socks on in the morning without pain and stiffness in his groin. To achieve a high level of commitment it is also essential to achieve a high level of verbal and non verbal communication (Chapter 3) and a self-critical approach to the task of translating the patient's story into a clinical picture that can be helped by manipula tive physiotherapy. This includes listening carefully and believing the information that the patient is giv ing, interpreting the non-verbal messages which are a reflection of illness experience and carefully consider ing the wording, relevance and impact of the next line of questioning. It is sad to hear patients say that their doctor or physiotherapist does not listen to them, or listen care fully enough, or listen sensitively enough, or listen in sufficient depth, when they want to discuss their disorder. The following quotation from The Age, an Australian daily newspaper, sets out the demands of 'listening' very clearly:
It is open-mindedness, mental agility and mental discipline linked with a logical and methodical process of assessing cause and effect which are the demands of the Concept.
THE MAITLAND CONCEPT - A MANIPULATIVE PHYSIOTHERAPY MODEL Introduction
The International Maitland Teachers' Association (IMTA) defines the Maitland Concept as a process of examination, assessment and treatment of neuromus culoskeletal disorders by manipulative phYSiotherapy (Hengeveld 2002). The Concept demands an open minded, non-judgemental, unassuming and flexible
Listening is itself, of course, an art: that is zuhere it differs from merely hearing. Hearing is passive; Listening is active. Hearing is voLuntanj; Listening demands attention. Hearing is naturaL; Listening is an acquired discipline. The Age (1982) Believing the patient is essential if trust between patient and clinician is to be established. We must believe the patient's subtle comments about the dis order even if they may sound peculiar. Expressed in another way, the patient and the symptoms are inno cent (i.e. the patient is giving a truthful report about the disorder) until proven guilty (i.e. the patient's report is unreliable, biased or downright false). In this
The Maitland Concept - an introduction
context the patient needs to be guided to understand that the body can reveal things about the disorder and its behaviour and that we (the clinicians) cannot know these things unless the patient expresses them. This central core of the concept of total commitment (putting the patient at the centre and making as much use as possible of the body's capacity to inform) must begin at the outset of the first consultation and be car ried throughout the total episode of care, right to the end, and should include: •
your wrist like this (performs a posteroanterior movement of the carpus on the radius and ulna), tell me the exact point at which the sharp pain deep in your wrist comes on.' •
Question 1 (Chapter 6) - 'In your own words, as far as you are concerned, what do you consider to be
your main problem(s)':
(a) Pain, discomiort, stiffness, weakness, swelling, fear of movement and many other symptoms (b) Functional loss of activities of daily living, job, hobbies, sleep disturbance, etc. (c) An injury resulting in pain and disability. •
Communication strategies (Chapter 3) - calibrated to the patient's frame of reference including: (a) use the patient's terminology (b) seek spontaneous information: - Where does it hurt? - What makes it worse, what makes it easier? - How did it start, when did it start? - How is your general health? - How have you been since 1 saw you last time? (c) listen for key words (which require an immediate response or confirmation of their importance): - 'I always seem to get the pain in my knee at work.'
- The soreness in my elbow started in the summer.' - 'After treatment my hip was sore up until
Tuesday.'
(d) inspire confidence and trust: - remove non-verbal barriers such as desks from between you and the patient - arrange the seating and plinth so that you are never looking down on the patient. •
Functional demonstration (Chapter 6) - asking the patient to 'show me' the function, movement, activity or position which the patient knows will reproduce the symptoms or which the patient knows will be difficult to perform.
•
•
Differentiation tests (Chapter 6) - 'Now you are squatting down you have a pain which you say you feel under your knee cap. Does it change if 1 squeeze your knee cap like this?' (adds patellofemoral com pression only). Palpation, passive testing and construction of movement diagrams (Chapter 6, Appendix 1) - 'When I move
•
•
Selection of mobilization technique (Chapter 8) - 'It seems that you get the pain and stiffness in your ankle when you have your weight on it as in walking. The best way I have found that reproduces your symptoms is for you to stand with your weight on your foot and for me to push on your fibula (pos teroanterior movement of the fibula). This will be the mobilization technique 1 will use and then we will see if the pain and stiffness with walking has changed.' Progression of treatment (Chapter 8) - 'You have the feeling that 1 now need to stretch your shoulder a bit firmer (into the quadrant position, Chapter 1 1 ) and that this will get rid o f the stiffness quicker, is that correct?' Decision to stop treatment (Chapter 5) - 'After all the treatment you have had on your knee you have the feeling that the mobilization has done its job. You are now about 80% better and you feel it just needs time and the exercises and rehabilitation you are doing now to get full recovery.'
Concept thinking, the symbolic permeable brick wall and the primacy of clinical evidence
At the heart of the Concept is what has been called the symbolic permeable brick wall. This flexible, open minded and non-judgemental approach to thinking about clinical presentations and how to treat them pro vides the clinician with the facility to explore all pos sible hypotheses relevant to neuromusculoskeletal disorders. The permeable brick wall separates the the oretical compartment from the clinical compartment in the clinician's mind. However, a free flow of informa tion can take place across the permeable brick wall for the purpose of hypothesis formulation and testing. This mode of thinking is not used in any other phil osophy of manipulative therapy; it is the strength of the Concept and the security of the therapist whose primary concern should be the importance of the clin ical compartment in the decision-making process. There are five requirements that enable the ther apist to make the most of the brick wall approach to clinical decision making, as follows.
The first requirement The first requirement is to learn to think in two dis tinctly separate compartments which, although separate
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MAITLAND'S PERIPHERAL MANIPULATION
[ Figure 1 .5
The two-compartment mode of thinking.
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� Figure 1.6 The symbolic permeable ·brick wall": theoretical and clinical compartments.
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and quite different, are interdependent. One compart ment should contain all the theoretical information (known and speculative) and the other compartment should contain all the clinical information about the patient's disorder (Fig. 1 .5). Because much of the medical theoretical knowledge (e.g. diagnosis, pathology, biomedical engineering, etc.) is still incomplete, it should not be given any opportunity to obstruct the searching for all the appro priate clinical facts associated with a patient's disorder (Le. its history, its subjective presentation and its effects on the patient's movements) (Fig. 1 .6). In the day-to-day encounters with patients, such obstruction is a frequent occurrence and the theory does spoil the clinical search, thereby affecting the treatment poten tial. The two-compartment modus operandi is there fore a demand requirement. It is helpful to imagine that the two interdependent compartments are separated by a symbolic, permeable, 'brick wall'.
This mode of thinking also allows for discussion about hypotheses and speculations about patients' clinical presentations without there being any restric tions placed upon the progress of knowledge and skill. It also encourages the formulation of sensible research questions and projects which take the physiotherapy profession forward in its understanding of the causes of disabilities, particularly painful disabilities. A bonus from the 'brick wall' is that the theoretical compart ment allows for the widest of thinking (in fact, it encourages it) while knowing that, if the thinking is correct, it must match the clinical compartment which must always be correct (Fig. 1 . 7).
The second requirement The clinician must know the history, the symptoms and the signs very clearly, and while keeping these at the forefront of thinking, full use can be made of the
The Maitland Concept - an introduction
F igure 1 .7
Freedom for speculation,
hypotheses and research.
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theoretical compartment in terms of formulating as accurate a diagnosis or classification as possible. In such a manner, as clear an understanding as is possible about the patient and the disorder can be achieved. Coping with diagnosis and diagnostic titles is diffi cult. Even within medicine, many diagnostic titles are somewhat inadequate or even incorrect; they may be merely linked to patterns of symptoms or even based on suppositions. Titles are often used loosely and even inappropriately. It is often impossible to arrive at a specific, complete diagnosis, yet the treatment required is clearly known. Many people consider that treatment should not be administered unless an accurate diagno sis is available. This is true to some extent; it is neces sary to know whether a patient's symptoms are believed to be arising from a musculoskeletal disorder rather than an active disease, but it is not always neces sary to have a precise diagnostic title. Provided that the word 'diagnosis' is used in the terms defined in Butterworth's Medical Dictionary (Critchley 1978) quoted below, there is no difficulty:
Diagnosis. The art of applying scientific methods to the elucidation of the problems presented by a sick patient. This implies the collection and critical evaluation of all the evidence obtainablefrom every possible source by the use of any method necessary. From the facts so obtained, combined with the knowledge of basic principles, a concept is formed of the aetiology, pathology, lesions and disordered functions which constitute the patient's disease. This may enable the disease to be placed in a certain recognized category but, of far greater importance, it also provides a sure basis for the treatment and prognosis of the individual patient.
Therefore the 'brick wall' mode of thinking caters for the recognizable syndromes and recognizable patholo gies, it caters for the partially diagnosed disorder and it also caters for the clinical disorders of the movement system which are yet to fall into any recognizable clas sification. In all cases the clinical compartment has pri ority over the theoretical compartment in the final treatment/management decisions. Take for example the diagnosis 'chronic tennis elbow'. Such diagnostic specificity may encourage narrow thinking in terms of the nature and a locality of the disorder. This may limit the examination and assessment of the problem and so confine treatment, which thus may be ineffective. By broader-based thinking, a detailed examination of the associated joint structures and muscles, the sensitivity of the neural tissue in the arm, neck and thoracic spine and their reaction to movement testing, as well as asso ciated cervical and thoracic joint examination, may reveal relevant comparable signs to consider in treat ment. By coupling this to all the other clinical features of the problem, a working hypothesis can be made in which all the components of the condition and its clin ical presentation fit together.
The third requirement The clinician is required to use words in particular ways. To speak or write in incorrect terms means that the thought processes required to choose the words must also be incorrect. The phrases used show very clearly the way the thought processes are working. A simple example may help to make this point clear. If a patient describes a symptom area and the clinician describes the patient's pain as being 'hip joint pain', this is a poor choice of words. To be true to the Concept,
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MAITLAND'S PERIPHERAL MANIPULATION
L i.e. true to the separated theoretical and clinical com partments of thinking, the words that should be used in place of 'hip joint pain' are 'pain in the hip area'. It would be better still if the clinician demonstrated the area of pain and said 'pain in this area'. To have used the words 'hip joint pain' indicates that the thought processes could include the thought that the hip joint is the cause of the pain. Obviously it does not mean that the thought processes must include this thinking, but it does mean that it could. On the other hand, by using the words 'hip area', or demonstrating the area of pain, indi cates that although the thought processes may include the thought that the hip joint could well be the source of the pain, it is virtually impossible for the subconscious thought process to include the thought that the hip joint is the source of the pain. This is an important and essen tial element of the Concept. Some readers may believe that attention to this kind of detail is unnecessary. Quite the opposite is true: if the correct choice of words is made with care, and with the right mode in mind, then the thinking processes must be right. And when this is so, the whole process of examination, treatment and inter pretation must be the best that is possible. A clinician's written record of a patient's examination and treatment findings shows clearly whether the thinking processes are right or wrong for this concept (Chapter 9).
The fourth requirement The clinician is required to choose a treatment tech nique in relation to the patient's signs and symptoms rather than the diagnostic title. However, the theoret ical compartment may influence the vigour and choice of the technique. For example, a patient may have been diagnosed as suffering from an 'acute subacromial bursitis' with severe pain in the area of the shoulder when trying to lift the arm out to the side. The tech nique of choice is likely to be an accessory passive movement of the shoulder or shoulder girdle per formed in such a manner that it achieves the desired effect of enabling the patient to lift the arm out to the side without experiencing as much severe pain. The acute stage of the disorder would require the tech nique to be gentle, soothing and pain modulating. Planning the treatment, therefore, demands logical thinking. The treatment carried out at any one session is chosen with care and it must make sense both logic ally and methodically. Each step in the planning of the whole treatment programme is made on the basis of the same logical methodical sense. Prognosis is another aspect of treatment that is deter mined logically. This is achieved by assessing changes in the patient's symptoms and signs effected by treat ment, at the same time relating to the hypothesis about
the diagnosis. Full use is made, therefore, of the two interdependent compartments of thinking to achieve the best end result. In such a way, when a seriolls dis order is present, the importance of accurate diagnosis takes priority. However, when the presentation clearly shows a movement system disorder is present, the clin ical compartment takes precedence.
The fifth requirement The clinician should be encouraged to apply and adapt the two-compartment mode of thinking to contempo rary models of clinical decision making. The brick wall approach to clinical reasoning is well suited to estab lished hypothesis categories and the decision-making models (Box 1.1) which are relevant to the manipulative physiotherapy management of neuromusculoskeletal disorders (Higgs & Jones 2000). Examination
Examination is analytical assessment at the initial con sultation. Clinical information is gathered, hypotheses made, treatment options planned and prognosis specu lated upon. Information is gathered and interpreted during the subjective examination (Chapter 6). The oretical and clinical hypotheses are formulated during the planning of the physical examination. The hypotheses are then put to the test during the physical examination and subsequently through the application of carefully
Hypothesis categories • Pathobiological mechanisms: diagnosis, mechanisms of symptom production (Fig. 1.8) • Dysfunction: impairment and disability - both physical and psychological (Fig. 1.9) • The source and cause of the source of the symptoms (Fig. 1.10) • Contributing factors (Fig. 1.11) Precautions and contraindications (Fig. 1.12) • Prognosis (Fig. 1.13) • • Treatmentl management (Fig. 1.14) Decision-making models • Hypothetico-deductive reasoning (Fig. 1.15) • Pattern recognition (Fig. 1.16) • Lateral thinking (Fig. 1.17)
The Maitland Concept - an introduction
Figure
1.8
Pathobiological
mechanisms. - Felt something 'go' when throwing javelin 2 days ago - Sore, sickly pain outer elbow - Local, red, swollen, hot, tender
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1 .9
Dysfu nction: im pairment !
di sab i l ity.
Torn fibres of the
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Source
1 .10
Source
and cause of the source
- Common extensor origin - Radiohumeral, radioulnar joints - Radial nerve
of symptoms. - Painful isometric testing of finger extensors - Elbow supination stiff and painful - 'Tingling' back of hand with ULNT 2B (Butler 2000) testing - Wrist extension stiff
- Shoulder quadrant stiff
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11
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MAITLAND'S PERIPHERAL MANIPULATION
c::: Figure
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1.12
Precautions and contra indications.
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Figure
1.13
Prognosis.
Contributing factors.
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1.11
�
The Maitland Concept - an introduction
Figure 1.14
o
Treatmentl management.
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� Figure 1.15
Hypothetico-deductive
reasoning.
Possible components: - Patellofemoral - Tibiofemoral - Hip - Lumbar spine - Alignment faults - Femoral nerve
Anterior knee pain
- Footwear/Biomechanics
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ligaments
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Pattern recog nition.
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MAITLAND'S PERIPHERAL MANIPULATION
Figure 1.17
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chosen and performed treatment techniques. All relevant treatment/management strategies should be con sidered for all relevant components of the disorder. Recognized clinical methods of history taking and routine examination by physical means are used and are not necessarily special to the Maitland Concept. The universal aim of any concept of manipulative physiotherapy should be to identify movement dis orders and maximize movement potential. However, knowing in detail the intensity, behaviour and rela tionship of pain, stiffness and muscle spasm during the test movements is special. Such care reveals to the clinician the evidence of 'through-range pain', 'end-of range pain', 'irritability' and the var ieties of 'latent pain', all of which are special and fundamental to the use of passive movement espoused by this Concept. There are particular details to examination procedures which are special and do relate to the Concept. Examination, therefore, should be logical, method ical, comprehensive and relevant (Wells 1988).
Subjective examination (C/O) The clinician should be able to 'live' the patient's symp toms throughout a complete cycle and 'feel' emotion ally what the patient is experiencing. The aims of the subjective examination should be to:
•
•
•
•
• • •
•
•
•
•
place the patient at the centre of everything that the clinician wishes to do identify, with asterisks (Chapter 6), the kind of disorder, the site, nature, bel;laviour and histor y of the patient's symptoms identify how the patient is affected and has been affected by the disorder (impairment/ disability)
establish the extent of the physical examination required and the desired effect of treatment based on the sever ity, irritability and nature of the symptoms and the stage of the disorder identify precautions and contraindications for treatment identify the structures at fault (the source/the cause of the source of the symptoms) hypothesize about the mechanisms of symptom production (nociception, per ipheral neurogenic, central, autonomic, affective) identify the factors contributing to the disorder hypothesize about the pathology involved identify clues to possible treatment techniques (e.g. the injuring movement, functional demonstr ation, or strategies which the patient has developed) establish factors which help to make a forecast for a favourable or unfavourable prognosis record findings in a logical methodical way.
Table 1.1 provides a summary of the subjective exami nation; Box 1.2 outlines the planning of the physical examination (planning sheet).
Physical examination (PIE) (Chapter 6) The aims of the physical examination should be to: •
•
Lateral thinking.
•
•
•
establish, with asterisks, the signs relevant to the patient's disorder test the clinical and theoretical hypotheses identified in the C/O analyse movements in ter ms of their range/ symptom response / quality apply an appropriate amount of examination (shor t of symptoms, up to the onset of symptoms,
The Maitland Concept - an introduction
Ta ble
1 .1
Su m m a ry of the subjective exa m i n a t i o n Question
Areas of symptoms
Where are the symptoms?
Fi l l in a body chart
1:
Esta b l i sh the k i n d of d isorder
Behaviour of symptoms
History of symptoms
Speci a l questions
Can I do harm?
What makes the symptoms
How did it start?
worse, what makes them better?
When did it start?
The effects of rest, activity and
The history of the present
position on the pain / symptoms
episode of symptoms from
precautions and
onset to present
contra ind ications to
Be aware that different
Determine all possi ble
kinds of pa i n (symptoms)
Be aware that the pain (symptoms)
can interact together in
can behave i n many different ways.
The history of 011 past episodes
physiotherapy and any
associated areas
It is necessary to know the behaviour
of the symptoms from onset
factors contributing to or
manipu lative
of the patient's symptoms if a
incl uding progression of
infl u encing the resol ution
Be aware that there co uld
reasonable understanding of the
symptoms
of the disorder
be overlapping areas of
status of the disorder is to
pa i n (symptoms) from
be determined
different components of
Determ i n e the stage in the natural history of the disorder
one disorder
• • •
• •
•
• •
to the limit of range, to the limit of range with overpressure added) reproduce symptoms find comparable signs establish the source, cause of the source and contributing factors to the disorder exclude structures not at fault confirm or rule out the need for caution with special testing (e.g. neurological examination, vertebral artery testing) follow a logical, methodical, comprehensive, relevant and integrated format record in a logical methodical way follow-up examination not completed at the initial consultation during subsequent visits (D + 1).
Physical examination should include the following (asterisk as you go along). Calibration of the symptoms (pain) pres ent before the physical examination commences.
Present pain
Alignment faults, protective/adaptive deformities, structural deformity, wasting, swelling and other signs of injury or disease. The effects on the symptoms/pain of correction or overcorrection of the deformity.
Observation (correct! overcorrect deformities)
Functional demonstration (functionally reproducing move ment, to P, or limit) When pain, rather than stiffness
is the problem, the patient can quite often demonstrate a particular movement, activity or function that will reproduce the symptoms (and it is the use of this that is
the aspect related to the Concept). Encouraging the patient to so demonstrate the movement, together with the clinician's analysis of it, is another aspect that is special to the Concept. Frequently the demonstrated movement may be used, or give an idea for the treat ment movement. When a comparable examination movement/pain response cannot be found, or when a sprain or injury has been the cause of the symptoms, re-enacting the injuring direction of the stress as an examination procedure may divulge the comparable sign. Again, such use in physical examination, which is routine in the Maitland Concept, is not found in other examination routines.
Injuring movement
Differentia tion tests are special tests that can be used when a test
Differentiation (including compression tests)
movement (active or passive), causing simultaneous movement of at least two joints or two movement sys tem structures, reproduces the patient's symptoms. The method is as follows: when the test movement is at the point in the range of reproducing the patient's pain, further movement is produced in one of the two j oints or structures, which, at the same time, either reduces the movement in the joint or retains it at an unchanged degree of mechanical stress. This test, which increases the stress at one joint or structure and reduces it at another will either increase or decrease the reproduced pain. The test is then performed in the reverse manner. The pain response (i.e. increase or
15
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MAITLAND'S PERIPHERAL MANIPULATION
[
A) REFLECTION OF THE SUBJ ECTIVE EXAMI NATION (Verification that the subjective exa m i nation is complete i n order to be able to start the physical exa m i nation a n d to perform a reassessment of subjective parameters - 'asterisks' - in subsequent sessions.) 1.
S u m m a ry of the main information of the subjective exa mination :
2. Agreed treatment objectives based on the findings of the subjective exa minatio n :
3. W h i c h subjective para meters ('asterisks') w i l l be used in subsequent sessions as part o f the reassessment procedures? (Describe the parameters i n sufficient deta i l ) :
4. Has t h e subjective examination been sufficiently comprehensive t o b e a b l e t o m a k e confident statements a nd t o develop hypotheses with regard to precautions and contra i n dications to physical exa mination procedures? (Check information of 'Q1 ', body chart, behaviour of symptoms, Hx, SQ):
B) HYPOTH ESES •
Dominant neurophysiological symptom mechanisms List the subjective information which supports the hypotheses of the various neurophysiological symptom mechanisms:
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I n put mechanisms - nociceptive symptoms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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I n put mechanisms - peripheral neurogenic mechanisms:
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Processing - central nervous system mechanisms a n d / o r cog n itive/affective /sociocultural influences: . . . . .
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Output mechanisms - motor and autonomic responses:
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Sou rces of sympto ms / i m pa irments List all the possible sources of a ny part of the patient's symptoms that must be exa m i ned :
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Joi nts underlying the symptomatic area(s):
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Joints referring into the symptomatic area(s):
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Neu rodynamic elements related to symptoms and dysfu nction:
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Muscles underlying the symptomatic area(s):
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Soft tissue structures underlying the symptomatic area(s) :
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Others:
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Neuromusculoskeleta l : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Contributing factors Which associated factors may be contributi n g / causing / ma i nta ining the problem and disabi l ity?: -
(a) as reasons why the joint/ muscle or other structure has become symptomatic/ as reasons why the disorder may recur (e.g. posture, muscle imbalance, muscle coord ination, obesity, stiffness, hypermobility, instability, deformity in neighbouring joints, etc.):
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(b) the effect of the disorder on joint stability: -
Medical factors:
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Cognitive factors:
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Affective factors:
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Behavioural factors:
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Specify: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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When do you expect to incorporate these factors i n physical exa mination procedures (im mediately / i n later sessions?). •
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Precautions a n d contra i n d ications to examination procedures and treatment interventions -
Yes / No
Are the symptoms severe / irrita ble?
(a) Specify your answer with examples from the subjective exam ination: (b) Is it possible that ongoing sensitivity takes place due to central nervous system sensitization or avoidance behaviour? Specify your answer: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
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Does the nature of the problem indicate caution? Yes / no (a) Tissue pathology: .
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(b) Other pathological processes (e.g. osteoporosis):
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The Maitland Concept - an introduction
17 ]
(c) Stages of tissue hea ling:
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(d) Stage of the disorder (Hx) (progressive/ regressive / static): . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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(e) Easy to provoke exacerbation or acute episode (sta bil ity of disorder): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(f)
Confidence to move/ extreme guarding of the patient:
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What are the impl ications of this answer with regard to the extent of the physical examination?: •
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Management - objectives / i f treating
local movement impairment - P or R 1 . Which short-term or long-term goals of treatment are pursued?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. If passive mobilization is a treatment option, do you expect to be treating pain, resistance but respecting pain, resista nce or resistance to provoke 'bite'?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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3. Are there any precautions or contra indications which need to be respected ('nothing at the price of . . . )?: . . . . . . . . . . . . . . . . . .
4.
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What advice should be included a nd / or measures would you use to prevent / l essen recurrences and provide the patient with a sense of control over the symptoms?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
C) PROCEDURES OF EXAM I N ATION •
Anticipation of the results of exam i nation procedu res -
Do you think you will need to be gentle or moderately firm with your exa mination proced ures?: . . . . . . . . . . . . . . . . . . . . . . . . .
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Do you expect a 'comparable sign' to be easy/hard to find? (if hard to find, 'functional demonstration tests' a n d 'if necessa ry
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tests' may be plan ned in advance, hence saving time). Explain why: -
What movements do you anticipate to be 'comparable'?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Might there be any positions or movements that need specific consideration during physical exa m i n ation? (e.g. lying i n
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prone positions): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . •
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Extent of examination procedures -
Any positions you may need to avoid in the exa m i nation? (e.g. prone lying):
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Which symptoms would you l i ke to reproduce?:
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Are there any symptoms which you would not want to produce? (e.g. dizzi ness, paraesthesia): . . . . .
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To what extent may you provoke symptoms? (list this for each relevant symptom area): Until the onset of P , / ca refu l ly
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beyond P, - maybe exploring 'Trust, ' / move to the limit of the test movements: -
Number of tests you will be performi n g : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Few tests (active short of l i m it) /Sta ndard tests without overpressure (active limit of movement) /Standard tests with overpressure (active limit plus overpressure ) / ' I f necessary' (or 'when appl icable') tests •
Which components do you exa m i ne and which tests (includ i ng reassessment procedu res) w i l l you perform i n the first session? . .
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W h ich components do you expect to examine in the second session? (And with which tests?) : . . . . . . . . . . . . . . . . . . . . . . . . . .
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W h ich components or contributing factors do you expect to exa m i n e in later sessions? (And with which tests?) :
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Sequence of exam i nation procedures of the first session:
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Observation :
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Functional demonstration test and differentiatio n :
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Active movement tests (specify w h ich):
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Isometric tests (with which purpose?):
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Specify which tests: -
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Are any special tests indicated?:
(a) neurological exa m i nation (conductivity): (b) others (e.g. insta b i l ity testing):
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Neurodynamic testing :
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Palpation a nd passive movement testing:
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(a) accessory movements (specify joint position; which acc. mvts) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (b) physiological movements:
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(c) others: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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When do you plan to perform reassessments d u r i n g the P I E procedures?
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(Indicate this with a double line behind the above-mentioned test procedures.)
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18
MAITLAND'S PERIPHERAL MANIPULATION
decrease) confirms which structure was found to be at fault with the first test (Chapter 6). Compression testing can be used when, during the physical examination, it becomes evident that the two joint surfaces should be held firmly compressed together when performing a test movement (Maitland 1 985). Only by adding such compression may the evi dence of origin of the patient's symptoms become clear (Chapter 10).
movement may be recorded with two ticks, as shown below, indicating its normality: F ,/ ,/
The F represents the movement being tested, in this case flexion. The first tick means that overpressure has been applied and that the range is normal; the second tick means that the stretch response to the overpressure has been normal.
Brief appraisal tests - peripheral and vertebral These are quick active tests of peripheral joints or regions of the spine to determine the degree to which they are involved or not involved in the generation of the patient's symptoms.
Isometric tests
Active movements - range/pain (symptom) response/ quality of movement (to P, or limit) - peripheral and spinal
Neurological examination and neurodynamic testing are described in detail in Butler (2000) and Maitland et al (2001) and therefore the descriptions of such techniques are not included in this text.
It is a mandatory rule in this Concept that when testing a movement in any direction, the recording of the findings must include both the range and the pain response and, when appropriate, the quality of the movement (this should include both active and passive movement). A detailed examination of movement seeks to reveal the smallest change in the behaviour of the pain and the limitation of the range with each direction of movement. For example, the patient may perceive pain or discomfort throughout the range or only to the end of the range (Chapter 8). The behaviour of the pain with the movement may match the behaviour of the resistance with that same movement within its avail able range. Appreciating the fine differences in behav iour of the abnormal elements of the movement is imperative to the best application of treatment: never
think of range without thinking of pain; never think of pain without thinking of range.
Combined movements Although the physical exami nation of routine physiological movements is not special to the Concept, the coupling together of these movements into any possible combination is. Com bining accessory test movements with physiological movements is equally important. The method of com bining movements should be determined more by the desire to provoke or relieve the patient's symptoms than by biomechanical considerations. The formaliz ing of these tests has been the original contribution of Brian Edwards (Edwards 1992). Overpressure When examining a movement of a par ticular structure, it can only be classed as being normal or ideal (Maitland et al 200l) if a firm overpressure can be applied without provoking anything more than the expected normal stretch response. Under these cir cumstances when the stretch response is normal and the overpressure has been of adequate firmness, the
Isometric tests are of value in testing for muscle function, strength and pain response only if it is considered that other structures may also be compro mised and therefore pain sensitive. In such cases further differentiation would be necessary (Kendall et al 1993).
Palpation of structures in the peripheral regions should be accompanied by an in-depth know ledge of surface anatomy (Hoppenfeld 1976).
Palpation
Passive movement (peripheral, vertebral)
Examining
accessory movements in both the loose-packed position and at the end of limited ranges, or in painful positions of a free range of movement, are, in one way, special to the Concept. Although assessing the range of acces sory movements appears in other concepts, assessing the pain responses in relation to the suffered pain does not, nor does the assessment of the pain response of accessory movements in a painful, yet not limited phys iological position. To know which accessory movement most closely relates to the patient's symptoms gives information about tl1e disorder which cannot be gained in any other way. This aspect is special to the Concept. The testing of functional corners - such as hip flexion/ adduction, shoulder quadrant, knee extension/ abduction - are special to the Concept in that a joint cannot be classed as normal unless these functional corners have been examined in detail and deemed so. Often, in patients with minor symptoms, physioLogical movements will be pain-free. However, when the func tional corners are examined it is possible to reproduce the patient's symptoms. Treatment is likely to be effect ive, therefore, if directed into these corners.
Movement diagrams Movement diagrams (Appendix 1) are included as part of the Concept for two reasons: 1.
They formulate a basis from which the clinician can learn more from each clinical experience. To draw a diagram representing the findings on examining
The Maitland Concept - an introduction
Rather than thinki ng about all the physical examination tests which it is possible to use for each structure of the movement system, both the novice and the experienced clinician should think about which tests for each compo nent can be carried out in each of the following starti ng positions (for the patient): • • • • •
Standing Sitting Side lying (R) (L) Supine Prone
•
•
For example, the following test seq uences may be used to examine a patient with anterior knee pain: •
•
Standing: observation (local and global) gait analysis functional demonstration, injuring movement, differentiation - brief appraisal of movements - active movements: knee, hip, foot, spine Sitting: - alignment faults with active knee extension - isometric quadriceps in varying degrees of knee flexion
a particular movement forces the clinician to analyse the relationship of the pain/stiffness/muscle spasm (joint signs) which may be present.
2. As a means of communication in the teaching situa tion, the diagrams provide a tool for learning which can be used in a way that is foolproof.
Selection and reassessment of treatment technique (Cha pters 5 a n d 8)
Physical examination techniques are frequently used as treatment techniques as well as to reassess the effects of treatment. A 'clinical tip' outlining an integrated approach to physical examination is shown in Box 1.3. Techniques of mobilization/ manipulation
Passive mobilization of all peripheral joints, whether they be synovial or non-synovial, is the basis for the techniques described in this book. However, passive
•
slump test passive patellofemoral movements in varying degrees of knee flexion Side lying: side lying slump (femoral, saphenous nerve) lumbar passive physiological intervertebral movements (PPIVMs) h i p accessory movements gluteus medius function, iliotibial ba nd length Supine: SLR - sacroiliac stress tests - hip: physiological, accessory movements, flexion / adduction palpation around the knee patellofemoral passive movements + compression tibiofemoral passive movements and functional corners q uadriceps lag test muscle length tests: rectus, il iotibial band, iliopsoas Prone: intervertebral palpation and accessory passive movements passive tibiofemoral movements in knee flexion passive movements in hip extension hamstrings / gluteus maximus function
movement can be applied to any structure of the movement system which has had its mobility comprom ised by injury, overuse or disease. The principles of the technique can be and should be applied to any move ment impairment (Banks 1997). Techniques as they apply to this concept are never ending and they never should have an ending. So long as patients present with different symptoms and signs, the clinician will have to think constantly how, when and why techniques can and should be modified and changed to free the patients of their symptoms. Although there are basic handling techniques which must be taught, the Concept demands that the clinician's mind must be so open as to allow for modifications of the techniques until they achieve what they have set out to achieve. The basic treatment techniques must include every movement of which the body is capable, both the physiological movements and the accessory move ments and all possible combinations of them. In each relevant chapter of this book techniques will be described in a way that relates to the fundamental
19
20
MAITLAND'S PERIPHERAL MANIPULATION
skills required for the safe and effective delivery of passive mobilization/ manipulation to the patient. For each technique consideration should be given to the following. •
•
•
•
•
to the use of accessory movements while the joint surfaces are compressed. •
The passive movement direction the passive move ment (physiological, accessory, combinations) direc tion or position which provokes or relieves the patient's symptoms. -
The symbol
the recognized abbreviation to denote the movement direction being used. The symbol always corresponds to the patient's anatomical planes of movement (Maitland 1 992). -
Figures/CD-ROM each technique described in the text will be accompanied by photographs and CD ROM clips to assist the reader in visualizing the dynamics of the skill required. -
Starting position of the patient basic starting posi tions and a variety of modifications are required to achieve the desired effect of the technique which is to relieve or provoke the patient's symptoms. -
Starting position of the therapist adapted to achieve the desired effect and to maximize the delivery of the passive mobilization technique. -
•
Localization of forces
•
Application of forces (method)
positioning of the hands, fin gers, thumbs and arms to produce the passive movement locally in the most effective manner. -
the method and style of the treatment technique should include the best use of the therapist's arm and body movements to achieve the desired amplitude, position in range, strength, grade, speed and rhythm of mobilization. When actually performing a technique, the clini cian must become as involved with the procedure as is the soloist musician when performing with a symphony orchestra (clinical tip: try to practise tech niques to different pieces of music which have dif ferent rhythms and tempos). There are two styles of technique with which the Maitland Concept is associated and which are essential to the clinician's manual skills if the best results in the treatment of neuromusculoskeletal disorders are to be achieved. 1. Techniques that include movement in an oscilla tory fashion (two or three per second). These techniques are performed within a range of movement that is neither painful nor affected by any stiffness or musc�e spasm. 2. There are times when adjacent joint surfaces need to be held firmly compressed together while per forming a movement technique. This also applies
•
Variations/adaptations treatment techniques can be varied and adapted in many ways to suit the patient, the therapist or the situation at hand. Alternative starting positions, localization of forces and style of mobilization may be needed to achieve the desired effects of treatment more readily. -
Uses/evidence-based practice some techniques have been found to benefit or suit some clinical syndromes or painful movement directions more readily than others. Additionally, some techniques may have been the subject of randomized controlled trials or clinical scientific study. -
There are, therefore, no set techniques or invariable techniques; there are no times when a teacher of manipulative physiotherapy should say 'you must always do it this way'. The only 'must' in this concept is that the treatment technique must achieve its intention both while it is being performed and after it has been performed. The clinician's mind must always be open; the teacher must never be dogmatic: a technique is the brainchild of ingenuity; a technique must be as indi vidual as the patient.
In essence it is essential to have an open-minded attitude towards treatment techniques, being able to innovate and improve freely unhindered by theory and to relate the techniques to the functional disturb ance, i.e. adapt, adopt, improve.
-
Assessment
Repeated assessment and analytical assessment are the means of evaluating and reflecting on everything done during the clinical decision-making process. 'Proof' of whether treatment is working or not is achieved by continually comparing the effects of the selected and progressed treatment techniques on the patient's symptoms and signs. At the same time hypotheses about the cause of the problem, the struc tures at fault, the pathobiological mechanisms, the fac tors contributing to recovery and optimum treatment strategies can be confirmed, discarded or changed. Analytical assessment is the most important skill of the evaluation/reflection process. Every aspect of the patient's disorder is considered in an effort to establish every detail about the problem in order to 'make fea tures fit'. Assessment and reassessment follow closely behind whereby continuous and repeated evaluation of the effects of treatment is carried out. Assessment and analytical assessment are considered to be skills of greater priorities than examination and techniques in the clinical decision-making process (Fig. 1 .18).
The Maitland Concept - an introduction
-f-- Analytical assessment •
•
•
Examination •
•
•
•
(Higgs S.J. Jones M 2000)
Hypothesis Pattern recognition Establish c/O P/E ..
-r-r-- Assessment/reassessment •
•
•
•
Desired effeCts
•
A means to an end
•
Selection and progression
•
based on detailed
•
assessmentlreassessment
•
•
•
Figure
1.18
Analytical assessment at the first consultation
During the initial examination of the patient, informa tion is gathered through the subjective and physical examination and should establish and test a working hypothesis about the kind of disorder that the patient has and by how much it is affecting everyday life. Consideration should also be given to the stage and pathological stability of the disorder. For example, a young man with acute, severe, irritable pain in the shoulder area after a recent injury may be having pro gressive difficulty putting a shirt on in the morning. He may have grossly restricted shoulder movement in all directions because of pain. The desired effect of treatment is to deliver pain-relieving mobilization techniques to his shoulder in order that he can carry out his daily activities with less painful restriction. Other modalities may also be necessary to facilitate the desired effects, such as explanation of the expectations for recovery, anti-inflammatory medication and home management strategies. 2.
'Proving' the clinical value of the technique Comparison of the effect of treatment Before each session During each session Immediately after treatment Periodically after every 3/4 sessions Retrospectively Final analytical assessment Prognosis/outcome
Representation o f the i m p o rtance of assessment and analytical assessment i n t h e c l i n ical decision-making process.
Obviously, the best treatment cannot be given without highly skilled examination and treatment techniques. However, flawless analytical assessment is the vital link in this concept of manipulative physiotherapy. It is the keystone, without which the whole concept would collapse. There are six categories of assessment relevant to each episode of care. 1.
The thinking underlying clinical practice
Initial analytical assessment
Techniques
•
'Making features fit'
Thinking one step ahead
Pretreatment assessment
Before every treatment session begins the effects of the previous treatment session should be evaluated. The
therapist, therefore, should start each session with the question: 'How have you been since I saw you last time?' Comparisons should be made of the effects of treatment on the patient's signs and symptoms since his last visit. Established daily activity limitations and movement impairments (CIO *** and PIE ***), such as the area or quality of pain, and the effects that activ ities, positions or particular times of day have on the pain, should be used for comparison. Likewise, any changes in protective deformities, functional move ments, passive movement, etc. should be assessed. 3.
Assessment and reassessment during and immediately after each treatment session
This is 'proving or assessing the value of a technique' in treatment. This entails knowing what the intention of the technique should be while it is being performed and having expectations of what changes the technique will effect follOWing its use. Two applications of a tech nique are necessary before it is discarded as being use less for the present stage of the disorder. The effects of treatment from one session to another should also be evaluated in detail. For example, the treatment selected for the above patient may be a grade I shaft rotation of the humerus which produces the desired effect of the feeling of movement without pain or discomfort. After 2 minutes of the slow oscilla tory passive technique the patient begins to experience an ache. This is not desired so the treatment is stopped based on the assessment of effects during the adminis tration of the technique. Immediately afterwards the patient feels the same level of discomfort as before the treatment but feels that he can move his arm a few
21
22
MA I TLAND'S PERIPHERAL MAN I PULATION
L
degrees further before he perceives an increase in pain, compared with before the treatment. Thus, by assess ing the immediate effects of treatment, a favourable though slight improvement is detected. Two days later a pretreatment assessment may reveal that the level of discomfort had diminished Significantly from the pre vious two days and that the patient had felt that his ability to put his shirt on was no longer getting worse by the day. Reassessment therefore helps in deciding the next course of action or progression of treatment. In this case it would be desirable to recreate the same effects as the previous treatment session.
The body's capacity to adapt, compensate and inform
The body has two capacities that influence assessment and must be borne in mind when making analytical assessments. Each of these capacities can have an effect on the development, rate of recovery and resolution of signs and symptoms. 1.
The body's capacih} to adapt
the body has an aston ishing capacity to adapt to changes that are forced upon it by congenital abnormalities, trauma, life long heavy work and disease -
2. The body's capacity to compensate the body also has an enormous capacity to compensate for damage and disease. -
4.
Progressive assessment
After every three or four treatment sessions it is wise to compare the patient's signs and symptoms over a longer period of time in order to gain an overview of the rate of improvement of the clinical features of the patient's disorder. For example, after four sessions the patient with shoulder area pain may have improved slightly between treatment sessions but the reduction in the area of the pain felt may have diminished quite significantly over the compared longer period.
5.
Retrospective assessment
Retrospective assessment is often valuable after a planned break from treatment to assess whether the disorder is spontaneously recovering, recovered faster during the treatment period, a combination of both of these or not recovering at all. For example, after hav ing treatment for 2 weeks at regular intervals the above patient is much better both in terms of pain and functional activity. He has a 2 week break from treat ment and returns almost problem free, thus indicating that spontaneous recovery is now taking place and any further treatment is probably unnecessary.
The body has one other capacity which can and should be utilized in assessment and this is the body's capacity to inform. The patient's body can tell him things relating to his disorder that can never be detected by the clinician, even by the most thorough physical examination. These are frequently subtle messages which the patient may comment upon, yet feel that they are almost too trivial to state. Nevertheless they may be priceless. The only way the clinician can elicit these subtleties is to listen to the patient, believe him and encourage him to mention anything that might be relevant, irrespective of how trivial or unimportant it may seem to him. The patient who is 'tuned in to his body' will be aware of these subtleties, and the clinician can educate the patient to notice these trivia and to report them. This is an essential way in which the patient can assist in the moment-by-moment subjective assessment of his dis order and its behaviour. The achievements possible through assessment are limited only by the extent of one's lateral and logical thinking. Therefore the clinician should think, pLan,
execute to prove. Recording
6.
Final analytical assessment
At the completion of the episode of care a final analyt ical assessment will be useful to determine, amongst other things, the future prognosis of any mode of treat ment and the likely recurrence of the patient's disor der. For example, the above patient can be expected to make a full recovery and return to his normal level of activity given the nature of the injury, the response to treatment and the natural recovery. Recurrences are possible if the patient is in a position during his everyday activities such that the same injury could occur again.
Recording of examination, treatment and assessment is a visualization of reasoning and reflects the discip line of the logical, methodical approach to decision making. The Concept encourages the clinician to com mit facts, thoughts, impressions and reflections to paper in a detailed but abbreviated form. The Concept demands that recording of patient information should be detailed enough to hold up to cross-examination in a court of law. Recording each treatment session (Chapter 9) should include: •
a quotation of the patient's opinion of the effects of the previous treatment as a comparison rather than
The Maitland Concept - an introduction
a statement of fact. For example - Comparison: 'I can lift my arm higher than I could last time'; Statement of fact: 'My shoulder still hurts when I lift my arm' (the immediate response to this answer is for the cli nician to say 'how does it feel compared with when I saw you last week?') •
•
•
•
•
pretreatment planning and reasoning behind the selection of treatment the treatment technique, its grade, its rhythm and its symptomatic response while being performed immediately after treatment, the patient's compari son of any changes in symptoms resulting from the technique re-examined movements, their range, symptom res ponse and quality compared with before treatment thoughts about how treatment may need to be modi fied at the next session. This will stimulate memories of the last treatment session and makes assessment complete in terms of knowing the path the treatment is moving along.
Context
The Maitland Concept is a holistic approach which not only seeks to clarify the physical components of an individual's movement disorder but also takes full measure of the many aspects of the individual's per sonal illness experience, lifestyle and emotional state and how these impact on the problems. While manual techniques of passive movement are the mainstay of the treatment methods in this Concept, other modalities
such as home programmes of active, functional exer cise and self-treatment procedures, the assessment and correction of muscle imbalance as well as atten tion to ergonomics in the workplace and recreational activities are incorporated as necessary, based on sound clinical reasoning and evaluation. Hence this system has developed as one which incorporates rather than excludes new methods and techniques of assessment and clinically valid treatment. Wells (1996) has developed a contemporary model of how the Maitland Concept is able to incorporate such issues as psychosocial factors and pain mecha nisms into the management of neuromusculoskeletal disorders (Fig. 1.19). Maitland (1987) says of the Concept, 'It did not "come" [to me] fully developed, but as a living thing, developing and extending'. Butler (2000) considers that 'the self-management concept of McKenzie, the inherent reasoning strategies of Maitland, the skill in joint management of Kaltenbom/ Evienth and Paris are superb aspects of management that we must never lose, but adapt'. Wright and Sluka (2001) conclude that 'emerging evidence therefore supports the concept that manual therapy techniques [mobilization of the cervical spine, specifically] exert important neurophysiologi cal effects that may contribute to the ability of these treatments to reduce pain'. However, they conclude that 'there is also a noticeable lack of studies address ing the use of manipulation or mobilization tech niques to treat peripheral joints'. COincidentally, various studies including that of Salter ( 1989) have concluded that passive movement
Figure Psychosocial (e.g. attitude, mood, stress)
.-I I I I I I I I I
Muscles and connective tissues
Postures Work practice General fitness
Joints
and associated tissues
Mechanisms (e.g. chronic pain)
1 .1 9
Components, mecha nisms and dimensions
relevant to manipulative th erapy. Reprodu ced by k i n d perm ission from We lls
( 1 996).
23
24
MA ITLAND'S PE RIPHE RAL MANIPULATION
seems to be the best means of promoting the healing of defects in synovial joint articular cartilage (Chapter 8). Maitland (1986) recognizes that pain 'is influenced by an enormous variety of factors and it presents in many different ways'. The nature of the person may require that treatment techniques are 'modified to suit the patient first and then suit the disorder ' (Maitland 1991). Likewise Gifford (1997) suggests that if pain and the patient's experience of pain are to be understood, the cognitive and affective dimensions of pain should be considered as well as the sensory dimensions, and that pain should be viewed in terms of these three interrelated mechanisms.
Hengeveld (1999), in her review of the WCPT description of physical therapy, notes that the adapta tion to the principles of the Maitland Concept can be recognized. Key words, such as assessment, examina tion of functional limitations, evaluation, clinical rea soning and re-examination, have their roots within the Maitland Concept. However, as we see and hear the term 'Maitland Concept' used less and less we recog nize its core features in the ever-developing science and practice of manipulative physiotherapy and other specialities of physiotherapy. If this process continues, Geoff Maitland will have had his wish.
References Banks, K. 1997. Passive techniques: a review of their use in clinical practice. In Rehabilitation of Movement: Theoretical Basis of Clinical Practice, ed. J. Pitt-Brooke, pp. 319-360. London: W B Saunders Butler, D. S. 2000. The Sensitive Nervous System. Adelaide: NOI Group Critchley, M., ed. 1978. Butterworth's Medical Dictionary, 2nd edn. London: Butterworth Edwards, B. C. 1992. Manual of Combined Movements, 1st edn. Edinburgh: Churchill Livingstone Gifford, 1. S. 1 997. Pain. In Rehabilitation of Movement: Theoretical Basis of Clinical Practice, ed. J. Pitt-Brooke, pp. 196-232. London: W B Saunders Hengeveld, E. 1999. Review of WCPT description of physical therapy. IMTA Newsletter, 6 Hengeveld, E., ed. 2002. International Maitland Teachers' Association Draft Rules and Regulations. Switzerland: Zurzach Higgs, J. & Jones, M. 2000. Clinical Reasoning in the Health Professions, 2nd edn. Oxford: Butterworth-Heinemann Hoppenfeld, S. 1 976. Physical Examination of the Spine and Extremities. New York: Appleton Century Crofts Kendall, F. P., McCreary, E. K. & Provance, P. G. 1993. Muscles: Testing and Function, 4th edn. Baltimore: Williams and Wilkins Maitland, G. D. 1985. The importance of adding compression when examining and treating synovial joints. In Aspects of Manipulative Therapy, 2nd edn, pp. 109-115. Melbourne: Churchill Livingstone Maitland, G. D. 1986. Vertebral Manipulation, 5th edn. Oxford: Butterworth-Heinemann Maitland, G. D. 1 987. The Maitland Concept: assessment, examination and treatment by passive movement.
In Physical Therapy of the Low Back, Vol 13, ed. 1. T. Twomey & J. R. Taylor, pp. 135-155. Edinburgh: Churchill Livingstone Maitland, G. D. 1 99 1 . Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann Maitland, G. D. 1992. Neurolmusculoskeletal Examination and Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G. D., Hengeveld, E., Banks, K. & English, K. 2001. Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Sahrmann, S. A. 2001. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby Salter, R. 1989. The biological concept of continuous passive motion in synovial joints, the first 18 years of basic research and its clinical application. Clinical Orthopaedics and Related Research, 242, 1 2-25 The Age. 1982. 21 August The Shorter Oxford Dictionary. 1980. The Shorter Oxford Dictionary on Historical Principles, 3rd edn. Oxford: Oxford University Press Wells, P. 1988. The Maitland Concept, Course notes assessment, examination and treatment by passive movement: The Maitland Concept, level 2. Switzerland: Bad Ragaz Wells, P. 1996. The Maitland Concept, Course notes: The Maitland Concept of Manipulative Physiotherapy, level 2a. UK: Rotherham WPCT. 1999. Description of Physiotherapy. 14th General Meeting, May 1999, Item 1 . 1 . Wright, A. & Sluka, K. 2001. Non-pharmacological treatments for musculoskeletal pain. Clinical Journal of Pain, 17, 33--46
25
Chapter 2
Mobilization and manipulation definitions. desired effects. role in rehabilitation and evidence base
THIS CHAPTER INCLUDES:
•
Definitions of mobilization and
•
•
Key words for this chapter
•
A glossary of terms for this chapter
•
The use of passive movement in clinical practice
•
The role of mobilization and manipulation in rehabilitation
manipulation •
Evidence-based practice and mobilization I manipulation.
The clinical 'desired effects' of mobilization I manipulation
KEY WORDS
passive movement. desired effects,
Mobilization, manipulation,
evidence-based practice.
GLOSSARY OF TERMS Activity intolerance - an individual's intolerance of movements or activities which they know to be painfully unacceptable or which they fear will harm them further. Chronic pain - pain which persists beyond the expected natural history of a condition or disorder. Alternatively, pain which accompanies conditions which are ongoing or recurrent such as rheumatoid arthritis or osteoarthritis. Deconditioned tissue - structures of the movement system such as articular cartilage, capsule and ligaments, tendon, contractile elements of muscle and neural connective tissue which have been underused functionally and lost their tolerance to activity
due to immobilization, chronic disuse or acquired loss of trust in movement. Desired effects - the effects which
Homeostatic facilitation - the context of rehabilitation of movement where the desired effects of treatment are to
are desired of a mobilization I
maintain ideal movement, tissue
manipulation technique, based
nutrition, tissue metabolism and
on what the patient wishes
structure or to restore them to an
treatment to achieve and the
ideal status.
role which mobilization and manipulation might play in this. Fear avoidance - due to current and
Hyperalgesia - an increased pain response to a painful stimulus. This may be primary (at the site of actual or potential tissue damage)
past pain experience, and
or secondary (at a site removed
misunderstandings about pain and
from the actual or potential tissue
tissue healing, a patient may be frightened of moving normally for fear of causing harm or being in
damage). Hypoalgesia - a reduced pain response to a painful stimulus.
pain. Consequently, patients will
Hypoalgesia is one of the proposed
avoid movements or situations of
pain-modulating effects of
which they are fearful. The result is often maladaptive movements
mobilization techniques. Joint signs - the abnormal physical
which compound and delay
findings or movement impairments
recovery.
which can be detected by a
26
M AITLAND'S PERIPHERAL M ANIPULATION
physiotherapist during passive
physiotherapist, anaesthetist,
movement of a joint. Such joint
employment agencies, clinical
signs include movement-related
psychologist, and family and
carried out in such a way that
pain (P), spasm-free resistance or
friends acting in a coordinated
periods of treatment and the
effort to achieve maximum
effects of treatment can be
potential recovery.
compared with periods of no
stiffness (R) and protective involuntary muscle spasm
(5). The
relationship of joint signs with
Single instance case study - the use of single patient case studies
Nociception - the experience of pain
joint passive movement can be depicted on a movement diagram.
treatment. The response of the
which is being generated at or near
patient in the comparable periods
the site at which it is felt and is
can go some way in determining
due to mechanical, chemical or
the effectiveness of a particular
the scope of practice of
ischaemic stimulation of
treatment in a qualitative
physiotherapy in ensuring that,
nociceptors in the injured or
framework. A number of single
through therapeutic intervention,
stressed tissue.
instance case studies can be
Maximizing movement potential -
each individual patient has the
Randomized controlled trials (RCT) -
analysed statistically in order to
opportunity to attain as much
scientific experimentation with the
enhance or reject the validity of a
functional movement as possible,
aim of answering a particular
treatment approach.
given their condition and health
scientific question through null
status.
hypothesis, randomized or double
Multidimensional
- (1)
Conditions
Sympathetic maintained pain - pain which persists because of
blinded allocation of representative
abnormally high or prolonged
which are multifaceted in terms of
populations, ethical and
output of sympathetic activity.
their presentation. For example, a
reproducible methods free of
patient with chronic frozen
contaminating variables, results
of research, the statistical analysis
shoulder may have developed
which can be statistically analysed
of all available quality studies or
Systematic reviews - in the context
stiffness in many of the joints of
and conclusions which may or may
trials on a particular subject,
the shoulder complex, the pain may
not answer the question asked.
modality or intervention. Such
have had both acute and chronic
Shaft rotation - mobilization
qualities to it and the pain may be
studies can then be rated and the
techniques whereby the movement
overall scientific acceptability of
compounded by fears that there
of rotation is performed about an
the subject, modality or
may never be full recovery. Thus a
axis which is along the shaft of a
intervention can be reported.
recognition should be made that all
bone. Generally this relates to long
the dimensions of the patient's
bones such as the humerus and
disorder must be addressed to
femur but can also be applied to
approach on a patient. If it does
bones such as the navicular. The
not work the approach can be
dimensional or multiagency
shaft rotation will produce roll,
refined either until it is abandoned
approaches to dealing with
spin and slide at the joint surfaces.
as ineffective or until it achieves its
conditions such as chronic low
In treatment, therefore, shaft
purpose.
maximize recovery.
(2)
Multi
back pain. In such cases the patient
rotation is often used in the same
may need the services of their GP,
way as accessory movements.
Trial and error - the process of using wise actions to try out a particular
DEFINITIONS OF MOBILIZATION AND MANIPULATION
manual traction, joint manipulation (short or long
The word 'manipulation' derives from the Latin word
lation which best suit the Maitland Concept are:
lever dynamic thrust) and joint mobilization'. The specific definitions of mobilization and manipu
manipulare meaning to handle, the use of the hands in a skilled manner, or skilled treatment by the hand.
•
The term 'manipulation' can be used loosely in clin
techniques include soft tissue manipulation, massage,
passive movements performed in
within the control of the patient so that movement can be prevented if the patient so chooses.
(1992) states that 'Many techniques
are considered manual therapy procedures and these
-
such a manner and speed that at all times they are
ical practice to mean passive movement procedures of any kind. DiFabio
Mobilization
•
Manipulation
-
(1) A passive movement consisting
of a high velocity, small amplitude thrust within
Mobilization and manipulation
27
J the joint's anatomical limit performed at such a speed that renders the patient powerless to prevent it. (2) Manipulation under anaesthetic (MUA) is a medical procedure performed with the patient under anaesthetic and used to stretch a joint to restore a full range of movement by breaking adhesions. The pro cedure is not a sudden forceful thrust as mentioned in the preceding definition, but is done as a steady and controlled stretch. This procedure can also be performed on the conscious patient. If adhesions are torn during mobilization techniques then the tech nique may be classed as a manipulation even though a sudden thrust has not been used.
Mobilization
Types of mobilization include passive oscillatory movements (two or three per second) of small or large amplitude, applied anywhere in a range of movement, typically for anything between 30 seconds and several minutes depending on the response and desired effects, or sustained stretching with or without tiny amplitude oscillations at the limit of the range. The style of mobilization can be refined further to include different rhythms of mobilization such as slow/ smooth or quick/staccato. These oscillations or sustained stretches may consist of accessory movement, shaft rotation, physiological movement and combinations of any of these.
Accessory movement Accessory movements are movements that a person cannot perform independently but can be performed on them by someone else (such movements primarily constitute the roll, spin and slide movements of joints described in Gray's Anatomy (Williams & Warwick 1980). However, it is worthy of note that accessory move ments can be performed on muscle tissue (Hunter 1994) and peripheral nerves (Butler 2000). The importance of restoring accessory movements to their pain-free, stiffness-free and spasm-free state cannot be underesti mated as the quality of physiological movement and therefore ideal functioning of the limbs is often depend ent on the quality of the accessory movements.
Physiological movement Physiological movements are those movements that a person can also carry out actively.
Movement combinations These include: • accessory movements/shaft rotation in the neutral range and symptom-free position or in any physiological position including the end of the available physiological range • physiological movements singly or in combination with other physiological movements or at the end of other physiological movements (e.g. glenohumeral medial rotation in extension and adduction) or into functional corners such as the shoulder quadrant or knee extension abduction/adduction • techniques which involve combining accessory and physiological movements at the same time (e.g. extension of the first carpometacarpal joint with a posteroanterior accessory movement) • any of the above performed while the joint surfaces are distracted/kept apart or compressed/squeezed together (note that distraction and compression can be used for examination or differentiation purposes as well as for treatment) • passive movements (often sustained) performed in functional weight-bearing positions or in conjunction with active functional movement (such as sustained transverse movement of the patella during active knee flexion and extension) (Fig. 2.1). • accessory or physiological movement performed in conjunction with relevant variations of neurodynarnic test positions, such as mobilization of the head of radius in the ULNPT position biased towards the radial nerve (Fig. 2.2). • the extent of one's logical and lateral thinking capacity is the only barrier to the potential possibilities for mobilization. Other definitions which may be relevant are joint move ment, neurodynarnics and neural movement.
Joint movement Shaft rotation Passive rotation of bones about their long axis gives rise to shaft rotation and accompanying accessory movement within a joint. Although in many cases a physiological movement, shaft rotation is often used to fulfil the same purpose as accessory movement.
Joint movement includes all of the intra-articular struc tures, the capsule and all of the non-contractile tissues which move during every passive and active movement of a joint. The 36th edition of Gray's Anatomy and particu larly the section on arthrology (pp. 420-503; Williams & Warwick 1980) is among the best references related to
28
MAITLAND'S PERIPHERAL MANIPULATION
current knowledge of joint structure and function. It is important to glean information fundamental to exami nation of joint disorders and treatment by mobilization/ manipulation from such texts. It is also important that physiotherapists treating joint disorders are well versed
in musculoskeletal anatomy as well as the principles of movement of each joint, the neurophysiology related to pain with joint movement and the part played by muscle spasm.
Neurodynamics Neurodynamics is the interaction between mechanical and phYSiological functions of the nervous system. Pathoneurodynamics may be used to describe the com binations of pathomechanical and pathophysiological events in neuromusculoskeletal disorders. 'Neuro dynamic testing' (straight leg raise, passive neck flexion, prone knee bend, slump, upper limb neural provocation tests), therefore, is the preferred way of describing how examination may evoke both mechanical and physio logical reactions in the nervous system (Shacklock
1995). Neural movement Neural movement relates to nerves and their infrastruc ture as well as the connective tissue which supports them and the connective tissue of the vertebral canal, foraminal canal and peripheral tissues through which they pass. The physiotherapist dealing with neuro musculoskeletal disorders should be well versed in: •
• •
Figure 2.1 Transverse movement of the patella (during active knee flexion and extension).
•
the courses of peripheral nerves in the head and limbs where they are superficial and therefore palpable the sites throughout their course where they are vulnerable to mechanical forces their relationship to and influence on the functioning of joints and muscles during daily life and during examination and treatment by manipulative physiotherapy.
THE USE OF PASSIVE MOVE MENT IN CLINICAL PRACTICE
Figure 2.2 Posteroanterior mobilization of the head of radius in the ULNPT 2B position (radial nerve biased).
Passive movement is defined as any movement of any part of one person which is performed on that person by another person or a piece of equipment; continuous passive motion (CPM) and machine traction, therefore, are procedures which also fall within the scope of the passive movement definition. Maitland (1987) points out that passive movement does something different from any other type of move ment in its clinical and therapeutic effects. Frank et al (1984) note that 'a spectrum of passive motion has evolved for various clinical purposes, includ ing diagnosis, correction of deformities, mobilization of stiff joints, stimulation of joint healing, neuromuscular
Mobilization and manipulation
re-education and prevention of immobilization compli cations'. They also note that 'clinical and experimental
THE CLINICAL 'DESIRED EFFECTS' OF MOBILIZATION AND MANIPULATION
evidence supports the probable effectiveness of passive joint motion on joint and tissue levels, but without a
Mobilization and manipulation show their best effects
better qualitative understanding of the mechanisms of
when directed at movement-related disorders, i.e. move
action, dose responsiveness, specific tissue effects and,
ments or positions that repeatedly cause the patient to
most important, their controls, passive motion will con
have symptoms and functional activity limitations.
tinue to be used suboptimally with inconsistent results. When these clinical and research deficiencies are cor rected, passive motion will attain its proper place as a powerful and reliable orthopaedic too!.' Salter
(1989) hypothesized, after 18 years of clinical
observation and experimentation, that CPM should
Restoring structures within a joint to their normal position or pain-free status so as to recover a full-range painless movement
A tear in a meniscus of the knee or damage to the menis
enhance the nutrition and metabolic activity of articu
cus in the temporomandibular joint will result in the
lar cartilage, stimulate regeneration of cartilage and
patient having a restricted range of movement which
accelerate the healing of both articular cartilage and
will be painful and limited in range in some directions. Passive movement treatment aims to alter the position
periarticular tissue.
(1995) advocates the use of passive
of the menisci so that the range of movement of the joint
mobilization to 'increase the flexibility of morphologi
becomes full and pain free. When pain-free movement
Van Wingerden
cally and functionally adapted connective tissues like
has been restored, the next step is to prevent recurrences
capsule, fascia, ligaments and retinacula'.
by exercise designed to maintain ideal alignment and
(1994) reminds us that if soft tis
functional stability of the joint. This aims to increase the
sues are not subjected to compression, shear and ten
strength, endurance and speed with which the muscles
Likewise, Hunter
sion forces, as in everyday life, the tensile strength of
can contract to control the movement. In the case of the
the tissue will decrease. Therefore, 'the key aims in the
temporomandibular joint, the joint may need to be pas
treatment of soft tissue lesions is to encourage the
sively mobilized in a variety of physiological directions
damaged tissue to regain its tensile strength as rapidly
while being distracted. This should be continued until
2.3). Subsequently,
as possible, and specific graded manual therapy tech
the desired effect is achieved (Fig.
niques can achieve this aim' during the various stages
exercises which facilitate the active control of jaw move
of the healing process. Butler
ments can be introduced (Rocabado 1985) (Fig.
2.4).
(2000) places passive mobilization in context
when referring to its role in the management of pathoneurodynarnic problems by suggesting that 'If passive mobilization is combined with or replaced by active educational-based approaches then this may be a better approach especially for chronic pain sufferers . .. .
Stretching a stiff joint to restore range Passive movement techniques can be used to stretch a stiff pain-free joint to improve the range of movement until it reaches the stage of being functional once more.
Passive movement in its various forms may assist restoration of tissue health and the movements may provide for more acute patient memory of the prescrip tion for an active treatment.' Frank et al
(1984) further note that there are poten
tial abuses of passive motion. These include causing additional damage, reinforcing nociceptive or sympa thetic activity, vascular embarrassment, nerve dam age, mobilizing unprotected joints and stretching the wrong tissue. Therefore careful consideration must be made about the force, direction, speed and duration of the passive movement procedure. Shekelle
(1994) emphasizes that 'the clinical res
ponse to [spinal] manipulation can be measured and quantified and the presence or absence of clinical bene fit should be the ultimate test of manipulation, rather than an understanding of the exact pathophysiological mechanisms'.
Figure 2.3 Temporomandibular joint distraction (longitudinal caudad movement).
29
30
MAITLAND'S PERIPHERAL MANIPULATION
Figure 2.5
Talocrural transverse movement in dorsiflexion.
Figure 2.4 Exercise to facilitate the active control of jaw movements.
The movements used should be those described in Gray's Anatomy (36th edn, Williams & Warwick 1980), Le. treatment movements which include the roll, spin and slide which are normal for that particular joint. There are other movements described in the text which are used to increase range. They should be performed as small strong oscillatory movements at the rate of two or three per second for up to 2 minutes (Van Wingerden 1995). The stretching can be repeated sev eral times or until the desired effect has been achieved. Passive movements performed in this way will pro vide the manipulator with more accurate 'feel' of the resistance than would be possible with a sustained stretching technique. When the patient experiences considerable pain during the stretching, the suggested oscillatory move ment must be performed much more slowly; there may even be no oscillation, but rather a slow and grad ually increasing movement stretching tight structures. When pain reaches a peak the movement is retained at that position, allowing time for the pain to decrease before attempting to take the movement further. It may even be necessary, if the intensity of pain sharpLy increases, to quickly slacken the pressure slightly so as to be able to sustain a holding position with an accept able degree of pain and to wait for the pain to decrease before attempting to take the movement further. The following statement is important to make at this stage, because it differs from the opinions and philosophies of other manipulators, yet is primary to the concept of this text:
When endeavouring to restore the patient's ability to achieve a certain movement or position (which may require restoration of more than one direction of
Figure 2.6 Inferior tibiofibular anteroposterior movement in eversion (can also be done in inversion).
physioLogicaL movement) two groups of movement (not just one) must be stretched. The first group consists of those physioLogicaL movements which are restricted (e.g. talocruraL dorsiflexion and inversion); the second group consists of the accessory movements that exist at the Limit of the restricted physiological ranges of movement. These accessory movements will also be restricted in their range in this position of the physiological range - for example, talocrural posteroanterior and transverse movement at the limit of dorsiflexion (Fig. 2.5), anteroposterior movement of the inferior tibiofibular joint at the limit of talocruraL eversion (Fig. 2.6). It is the first group of this section to which other manipu lators have taken exception, yet it is a primary element
Mobilization and manipulation
which this book embraces. In the case of the example given, to enable the patient to walk up hills and on uneven ground without experiencing pain and stiffness in the ankle, although stretching accessory movements may gain an initial improvement, this should be fol lowed up by stretching the physiological movements to achieve full restoration of range. Stretching
Mobilizing techniques to stretch have three other desired effects: • •
•
slow passive movement to retain range stretching to increase an otherwise normal range to make it more mobile (perhaps some would call it making the range hypermobile) stretching to lengthen contracted, fibrosed or shortened muscle tissue.
Stretching to retain range The thought behind this statement is really using the word 'stretch' incorrectly. When a patient is in an active phase of any of the arthritides, there is value in endeav ouring to prevent losing range of joint movement.
However, this should not be done at the expense of exacerbat ing the pain or prolonging the inflammatory response. The movement, therefore, should be neither oscillatory nor repetitive. The movement should be a single movement in the functional directions that are important for the patient's daily needs. Obviously the treatment move ment should not be forceful. Similarly the movement should be performed very slowly and well within the patient's comfort to achieve its desired effect of retain ing the range.
Stretching to increase the normal range There are many fields of endeavour (e.g. sport and dance) where it is necessary, for participants who have special potential, to have a greater range of movement than is normal for the average person. For a ballet dancer to achieve recognition as a good dancer, good 'turn-out' is essential. Some young dancers have this either naturally or gain it by their exercise and training programmes. Others may have good range for other aspects of dance such as 'point' yet be lacking in 'turn out' despite persistent training. When such a person has very good potential in the other requirements of a professional dancer, passive mobilization by a physiotherapist can be utilized to gain range in 'turn out'. When this is applied, the dancer's active training, functional stability of the newly acquired range and warm-up/warm-down must be coupled with the
Figure 2.7 Transverse mobilization of gastrocnemius in a stretch position.
stretching treatment. Additionally, the dancer should not experience any latent pain reaction from treatment (Chapter 14).
Stretching contracted, fibrosed or shortened muscle tissue In these stated circumstances, the movement used should be one that stretches or lengthens the muscle. This will primarily be a physiological movement but be aware that the muscle tissue may need to be stretched in other planes to achieve full restoration of range (Hunter 1994). For example, having tom a gastrocnemius muscle a dancer may need to be treated with specific soft tissue mobilization or passive stretching of the muscle in directions other than the lengthening direction. One treatment technique may be to stretch the muscle func tionally and then apply a specific passive transverse stretch at the site and in the direction of the injury in order to regain full range and function in the muscle. Consequently the risks for recurrent injury will be reduced (Fig. 2.7). Other forms of manual physiotherapy treatment should also be used to both assist in the lengthening of
31
32
MAITLAND'S PERIPHERAL MANIPULATION
[ the contracted tissue (e.g. proprioceptive neuromuscu
or emotional/psychological perceptions of pain. Other
1997) and to restore
therapeutic strategies or treatments need to be employed
lar facilitation, PNF) (Pitt-Brooke
the muscle to its preferred role as a mobilizer or a sta
to deal with these factors.
(2001) describes in detail the meth
If a patient has an active osteoarthritis in a joint, mobi
ods of achieving this and therefore such techniques are
lization will not improve the pain but anti-inflammatory
bilizer. Sahrmann
medication or intra-articular injections may. However, if
not included in this text.
the diagnosis is osteoarthritis, passive movement should always be a foremost consideration because symptoms
Relieving pain by using special techniques
may well be mechanical or movement related, being
A patient may have considerable joint pain which limits
superimposed onto previous joint changes. It is in this
active movement, although there is no loss of passive
area of determining what is the best thing to do to help a
range. In other words, if the examiner were prepared to
patient with distreSSing, yet not disabling, symptoms
ignore the patient's pain and press on regardless, the
that the physiotherapist has an important role to play in
range of movement would be full in all directions
conjunction with the referring medical practitioner. The
though obviously this would be extremely painful.
patient with post-traumatic arthritis and an exacerbation
Mobilization has a definite part to play in the treatment
of symptoms without obvious signs of inflammation is a
of these painful joints if it is identified that the joint or
good example of this.
tissue being moved
Most patients referred by doctors to physiotherapists
is the source of the patient's pain.
Within these joint disorders there is usually a degree
for treatment of musculoskeletal disorders do so
inflammation,
the cause of which is not always evi
because of pain rather than stiffness. Joints should be
primary
tested for range and pain, muscles should be tested for
hyperalgesia and symptoms produced predominantly by nociceptive mechanisms (Wright & Sluka 2001). The
tested for range and pain. If examination is carried out
of
dent. This will be accompanied by a degree of
length, strength and pain and neurodynamics should be
inflammation may be caused by systemic processes
correctly it will be found that most neuromusculoskele
such as rheumatoid arthritis or its variants, or it may be
tal disorders have more than one relevant movement
as a result of a mechanical or movement-related irritat
component and each of these components will have,
ing origin such as strain or sprain of the joint tissues.
within them, a pain component and a stiffness compo
The latter can be successfully treated by special passive
nent. Spasm may also be present and this may cloud the
movements; if the passive movement treatment elimi
assessment, particularly if it prevents movement early
nates the movement-related irritating cause, the patient
in the range. These components can be classed as 'joint
will lose the pain.
signs' which are abnormal physical findings of pain and
The patient may have more than one cause of inflam
stiffness, or protective involuntary muscle spasm pro
mation, primary hyperalgesia and nociception occur
duced during passive testing of a joint or for that matter
ring in the joint. For example, it is common for a patient
other neuromusculoskeletal structures. The interrelation
to have osteoarthritis producing an inflammatory reac
ship of 'joint signs' should be reCOgnized, as should their
tion superimposed upon a mechanical or movement
independence. All physiotherapists have treated a stiff
related factor provoking further inflammation. When
painless joint; they will also have treated patients with
this is so, passive movement treatment can effect a
pain associated with stiffness. However, it is surpris
degree of improvement commensurate with the extent
ing how few physiotherapists recognize the group of
of the movement-related cause.
patients who have painful joints that are not limited by
At the first consultation the clinician is aware that it is impossible to determine whether a combination of
stiffness. It is important to be aware that (a) such patients
do exist and (b) that they can be treated by special passive
factors is causing the painful reaction. However, if a
movement techniques directed at the joint pain. When
short trial of controlled passive movement is adminis
this concept of treating the pain component is under
tered, the extent of the mechanical or movement-related cause can be determined, in retrospect,
by assessment.
If
stood, accepted and used, then treatment by manipula tive physiotherapy can be utilized to its fullest extent.
the treatment lessens the patient's pain and improves range then at least part of the patient's pain must have been mechanical or movement related in origin. How ever, if there is no improvement, there is no mechanical factor to the pain and it may be being generated by systemic/autoimmune inflammatory factors or by other
Restoring neurodynamics to their ideal state to provide an ideal environment of mobility within which the nervous system can function optimally Consideration should be given to passive mobilization
mechanisms of symptom production such as referred
techniques performed with an emphasis on recog
pain, neurogenic inflammation, central/higher centre
nized neurodynamic test positions. In this way ranges
processing mechanisms, sympathetic maintained pain
of movement may be increased to achieve the desired
Mobilization and manipulation
effect of providing enough mobility in the limbs and trunk so that the nervous system can function opti mally both mechanically and physiologically. Neuro genic massage and mobilization of tissue surrounding nerves may also go some way to helping achieve this desired effect. Butler (2000) in his book The Sensitive Nervous System comprehensively describes such tech niques in detail and these are therefore not included in this text. THE ROLE OF MOBILIZATION AND MANIPULATION IN REHABILITATION
Sports injuries and trauma
Sports injuries can be considered in two categories: the 'over-use', 'misuse' or 'abuse' category, and the trauma category. Patients who have their cause in the over-use, misuse or abuse category form a special group because people competing in any sport subject their bodies to the maxi mum level they can achieve to fulfil their genetic poten tial. By continuous training and competing they may place a greater stress on some structures than they are able to stand. This extra stress superimposed on an 'overuse' situation will result in symptoms. The treat ment of the symptoms requires many forms of physio therapy of which manipulative physiotherapy is one. It is not necessarily the main one, but it is an aspect of overall management which is neither adequately recog nized nor used. However, it does play a major role in prophylaxis. The trauma category relates to injuries caused by blows and falls, particularly in the heavy contact sports. Other traumas under this heading include injuries sustained as a result of car accidents, machin ery and other industrial-related injuries and even post surgical trauma. All comprise damage to what may otherwise have been healthy tissue. As with the first group of sports injuries, many forms of phYSiotherapy, including manipulative phYSiotherapy, have a role to play in treatment. What many people do not seem to realize is that passive movement treatment can achieve desired clinical changes which other forms of physio therapy cannot. For example, achieving maximum range of joint movement and muscle length, achieving best results from the effects of pain inhibition, and helping to clear a protective muscle spasm may be best attained by mobilization. Creating an ideal environment for healing
Early movement after injury appears to be what is needed to achieve the best possible recovery (Butler 2000). This may well include passive mobilization in
conjunction with advice on active exercise and other forms of physiotherapy. Quite often patients are reluc tant to move actively after an injury. Early use of gentle passive movement may be the means by which an ideal functional environment can be maintained. Passive movement will also create an ideal environment for the damaged tissue to maintain adequate nutrition and metabolic activity (Salter 1989). The hypoalgesic and sympathetic effects of mobilization (Sterling et al 2000) will also provide much needed pain relief and influence the immune responses to injury (Gifford 1997). Complementing the healing process
Rehabilitation after injury or a prolonged inflammatory response, as in a 'flare-up' of arthritis, needs to be tai lored to the injury/inflammatory response and to the functional requirements of the patient. The desire to restore pain-free, stiffness-free and spasm-free full range movements may be enhanced by graded passive stretch ing to influence collagen alignment and tissue compli ance (Frank et al 1984) and to maximize the tensile strength of the damaged tissue (Hunter 1994). Making sure that the joint's 'functional corners' are pain-free and full range, for example, may well enhance the ability of the muscles to regain their normal strength and endurance by ensuring that residual swelling or pain is not inhibiting the neurophysiological reflex arc. Examples of this phenomenon may be seen in patients who only regain full strength in the quadriceps muscles when the post-meniscectomy knee can fully extend without pain or the improvement in the rotator cuff muscle strength after mobilization and stretching of the shoulder into the 'quadrant' or 'locking position' (Chapter 11). Kick starting the healing process by removing barriers to recovery
Patients often consult phYSiotherapists or are referred to physiotherapists long after an injury because their symptoms and functional restrictions persist - they say that they just do not seem to be getting any better. It is therefore the task of the physiotherapist to identify and deal with the reasons for lack of progression of the disorder through its natural history. There may well be cognitive or emotional reasons for this which need to be considered but there are also likely to be move ment impairments which need to be treated in order that the healing process may recommence. In this way the symptoms and restrictions can resolve. Take for example the footballer who has strained his groin making a tackle, yet several weeks after the injury he still experiences pain in his groin and cannot run flat out. A thorough neuromusculoskeletal examination may
34
MAITLAND'S PERIPHERAL MANIPULATION
[ reveal the injury has left him with minor but very painful limitation of hip flexion/adduction (Chapter 14). After one or two treatment sessions of sustained stretching with minimal oscillations into hip flexion/ adduction he reports that he was very 'sore' in his groin for several days after treatment but he feels that this has done the trick and his pain has gone and he can run faster. The physiotherapist should not be happy with this until any muscle imbalance, neurodynamic restric tion, spinal or other lower limb impairments have been identified and dealt with, thus making sure that the patient can maximize his movement potential. Retain an optimal functional environment to attain maximization of movement potential
This may apply to the sportsman who is involved in full contact sports or who pushes himself to the limit and is constantly injuring himself, or to the patient with arthritis who experiences repeated or periodic 'flare-ups' of the condition. Such patients may need constant reappraisal of their ranges of movement in order to retain an optimal level of mobility for their functional requirements. Take for example the javelin thrower who is repeatedly exposing his elbow to 'overuse' and 'abuse' resulting in stiffness and pain in elbow extension abduction/ adduction and flexion adduction/ abduction (Chapter 12). Likewise, the patient with rheumatoid arthritis whose propensity to rest very painful joints in their most comfortable posi tion during an exacerbation of their condition may well lead to the development of joint contractures. The extended role of passive mobilization
Complementing proprioceptive rehabilitation after injury and enhancing active rehabilitation programmes Clinical science has shown that proprioceptors within joints are stimulated when passive movement is applied to the joint (Zusman 1986). Therefore passive movement may be a useful adjunct to rehabilitation which emphasizes the need for sound proprioceptive recovery. In rehabilitation after cruciate ligament repair of the knee, Barnett (1991) has highlighted the impor tance of proprioceptive training in the functional recov ery of patients undergoing cruciate ligament repair. Early movement, including passive movement, in con junction with recognized protocols of proprioceptive re-education may be of value.. Likewise, Butler (2000) suggests that passive mobilization may be of value as a means of providing input to enhance the full potential of active functionally based approaches. For example,
a patient may need to relearn the ideal position of the scapula as part of the process of regaining scapulo humeral functional stability. By repeatedly moving the scapula passively the therapist will help the patient to sense the ideal position which can then be reinforced actively. Complementing reconditioning of tissues and regaining trust in movement Other uses of passive mobilization include: •
•
•
complementing the reconditioning of tissues of the movement system after prolonged periods of disuse complementing the process of regaining trust in movement which may have been lost due to fear avoidance or activity intolerance complementing the process of gradually exposing the patient with chronic pain to movements which they do not trust.
Passive mobilization techniques performed in a skilled manner may be a means of introducing deconditioned tissues to movement. Structures that have not been used maximally for a long period of time may need to be gradually reintroduced to the forces which they need. Take for example the patient who has been in a coma for several weeks on an intensive care unit after contracting encephalitis. Afterwards the patient's shoulders are too sensitive and painful to move actively but passive mobi lization techniques allow the shoulders to be moved in a way that begins the reconditioning process. Active movement can then be introduced when the patient is ready. Passive mobilization techniques may also be one of the multidimensional strategies used by physiothera pists in the management of chronic pain disorders (Waddell 1998). However, the physiotherapist must take great care in choosing the correct patients, and selecting the timing and the duration of such interven tions. Passive mobilization techniques may be one method of enabling the patient with chronic pain to regain trust in movement that has been avoided because of fear of damage or fear of exacerbating pain. For example, pain-free passive mobilization techniques which are modifications of upper limb neurodynamic tests may be used to introduce the patient to pain-free movement in a limb that is chronically painful and sen sitive to movement after a severe nerve root entrap ment. If the therapist is skilled in handling the very painful limb the patient may be helped to regain trust in movement and trust in the therapiSt. The patient is then more likely to regain trust in their active functional movements.
Mobilization and manipulation
Passive movement treatment as a means to an end Passive mobilization techniques should be used clin ically as a means to an end, whether to regain optimal ranges of movement, or to ensure that a disorder pro gresses through its natural history in the best way, or to complement rehabilitation programmes. Passive movement techniques, therefore, should be part of the dynamiC, multidimensional process of 'homeostatic facilitation'.
EVIDENCE-BASED PRACTICE AND MOBILl ZATION/ MANI PULATION
There are many variations of the definition and descriptions of evidence-based practice or evidence based medicine. Evidence based medicine is:
. . . the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Sackett et aJ
considered along with all the clinical information gath ered about the patient ill order to make the best thera peutic intervention for that person (Fig. 2.8). Scope of practice
Before discussing the evidence-base for mobilization and manipulation in clinical practice it is worth placing manipulative physiotherapy within the context of the physiotherapy professions as a whole. In the United Kingdom the Chartered Society of Physiotherapy Rules of Professional Conduct, Rule 1 , Scope of Practice (Bazin & Robinson 2002) states that:
Physiotherapy is an applied science, which possesses its own knowledge base, its own educational methods and practical application based on that knowledge. This is supported by the best available evidence of effectiveness. Physiotherapy research links theory and developing practice. This practice has, at the same time, retained its links to three core skills: •
• •
(1996)
In taking a broader, more realistic and comprehensive view of evidence-based practice, we define evidence as knowledge derived from a variety of sources that has been subjected to testing and has been found to be credible. Higgs & Jones (2000) The symbolic permeable brick wall separates the theo retical compartment from the clinical compartment in the physiotherapist's mind (Maitland 1991). Evidence based practice is essentially clinical decision making based on the philosophy of the symbolic permeable brick wall (see Fig. 1.3), i.e. all theoretical knowledge is
manual therapy (including massage, mobilization and manipulation) electrotherapy (electrophysical agencies) exercise and movement.
Mobilization and manipulation are well-established terms and physiotherapeutic core skills. However, there is still a mismatch between what highly trained and experienced clinicians experience every day (i.e. the clinical effectiveness of appropriately applied manipu lative physiotherapy) and the lack of clinical science and mature research evidence to support this. The lack of evidence and lack of appropriate patient-centred research focusing on the process rather than the modality does not mean that the use of mobilization and manipu lation within the physiotherapy profession should be used less or that training physiotherapists to a high
Figure 2.8 Evidence-based practice applied to the symbolic permeable brick wall.
Theoretical Compartment
Research evidence
- Clinical science
o
o
�
o
o
�
35
36
MAITLAND'S PERIPHERAL MAN IPULATION
L level of manipulative physiotherapy skill should not be important. In fact the physiotherapy profession should strive harder to answer the many research questions which still need to be asked about this physiotherapeu tic core skill. The evidence about mobilization and manipulation which is currently available can be categorized into evidence from: • • • • • •
systematic reviews randomized controlled trials clinical science single instance case studies expert opinion trial and error - within the safety margins of professional scope of practice.
Systematic reviews Systematic reviews and meta-analysis are considered to be the most reliable form of scientific evidence avail able. Their limitations are clear in that often the trials which they review are considered to be of poor quality in terms of their design and the statistical analysis of their results. Systematic reviews of mobilization and manipula tion are rarely conclusive one way or the other. Trials of mobilization and manipulation are fraught with difficulty in terms of population size, ethics, ran domization, reliable method and blinding. This proba bly means that such forms of scientific scrutiny are not suitable for patient-centred and process-orientated, rather than modality-orientated application of profes sional skills in the clinical setting.
Randomized controlled trials (Wrig ht Et Sluka 200 1 ) The jury i s still out! Manipulation of spinal joints has been the subject of many randomized controlled trials (RCTs). However, there have been few RCTs which specifically investi gate joint mobilization. Likewise, there is a lack of studies addreSSing the use of manipulation or mobiliza tion in treating peripheral joints. Early meta-analyses suggested beneficial effects of spinal manipulation and mobilization on measures of pain, flexibility and phys ical activity, although the effects were considered to be short term. Mobilization and manipulation appear to elicit short term beneficial effects in the management of low back pain of less than 3 weeks' duration and are probably of short-term benefit in the management of acute and sub acute neck pain and muscle tension type headaches.
In the context of rehabilitation, short-term relief of symptoms will enhance the patient's ability to stay active, on the one hand, and to help exercise pro grammes become more effective on the other. In this context, therefore, mobilization and manipulation become a means to an end rather than a quick fix.
Clinical science (Sterl ing et al 2000) Mobilization techniques applied to the cervical spine elicit concurrent changes in: • •
•
pain perception (hypoalgesia) autonomic function (increased skin conductance, decreased skin temperature) motor function (facilitation of deep neck flexor muscles).
These patterns of change are similar to the pattern of change elicited by direct stimulation of the periaque ductal grey region of the midbrain. Mobilization tech niques appear to exert a predominant influence on mechanical nociception (via dorsal periaqueductal grey modulation) rather than thermal nociception.
Single instance case studies Riddoch and Lennon (1991) have suggested that the single instance case study method of research is valid as long as the number of case studies related to a partic ular approach are sufficient to stand up to statistical analysis. Case studies in isolation have no value as research evidence but are of great value for other rea sons. Presentation of case shldies where manipulative physiotherapy has been used can be valuable in high lighting management strategies for some recognizable syndromes such as shoulder impingement or osteo arthritis of the hip. Discussions can provide useful learning opportunities about the selection and progres sion of mobilization techniques. There may also be opportunities to develop further research questions about the application of manipula tive physiotherapy to certain conditions. In a recent clinical seminar on anterior knee pain at a hospital in the UK a case study was used to emphasize the need for the physiotherapist treating such conditions to explore all avenues of therapeutic intervention. Such avenues included assessment of alignment faults in the lower limb, neurodynarnic evaluation, and hip and spinal examination as well as attention to the local structures around the knee. Consequently, a participant of the seminar went away, thought about her clinical practice for such conditions and applied some of the informa tion she had received. The result was that the next
Mobilization and manipulation
patient she saw with anterior knee pain, a 12-year-old girl, was successfully treated and managed using strate gies which previously were not within the physiothera pist's clinical repertoire. Expert opinion Expert opinion may include opmlOns of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees (Moore & Petty 2001). Physiotherapists are increasingly being called upon as expert wih1esses in courts of law. They are asked to apply their knowledge, experience and skill to give expert evidence which is often used as admis sible evidence in cases relating to, e.g. accidents or medical negligence. Likewise, on a day-to-day basis, clinicians are more likely to follow a course of action based on advice from a more experienced colleague than pure research evidence. Clinical experience and highly skilled practitioners are vital to the infrastruc ture of a profession with its own body of knowledge. The passing on of that knowledge and the develop ment of innovative ways of applying it are crucial to the physiotherapy profession. To use the term guru in its seemingly derogatory sense (Muncy 2000) rather than the term expert opinion is not at all helpful to the day-to-day practice of many physiotherapists who need accessible guidance to help their decision making and clinical skills develop with confidence. Trial and error Scientific discovery has often been made by mistake. Because of the infinite uses of mobilization and manipu lation (the technique is the brainchild of ingenuity) and because of the individuality of each patient, physio therapists are often forced to use trial and error to
solve a person's clinical problems. Trial and error in manipulative physiotherapy is often within good clin ical reasoning parameters. It is also within the scope of physiotherapy practice and it often leads to innovative practices. The key to the use of trial and error is in the demands of this concept for continuous and repeated assessment of the clinical effects of mobilization/ manipulation techniques. Trial and error, therefore, is a valid method of solving clinical problems. Sometimes it is the best way and sometimes it is the only way. Take, for example, a patient with pain around the wrist during extension of the wrist and hand. The sequence of examination, treatment and reassessment may go something like this: •
•
•
•
•
•
•
•
wrist extension is painful, extension of the radiocarpal joint is most painful (Chapter 13) stretching radiocarpal extension - pain stays the same stretching radiocarpal extension with the joint distracted - more pain created stretching radiocarpal extension with joint compression - pain stays the same posteroanterior mobilization of the lunate bone - pain stays the same posteroanterior mobilization of the scaphoid bone - pain becomes less anteroposterior mobilization of the lunate - pain also becomes less anteroposterior mobilization of the lunate with posteroanterior mobilization of the scaphoid - pain becomes much less.
Therefore, by a sequence of trial and error test treat ments a solution has been found to a movement-related painful condition by the making of deliberate choices.
References Barnett, D. S. 1991. Proprioception and function after anterior crudate reconstruction. British Journal of Bone and Joint Surgery, 73B, 833-837 Bazin, S. & Robinson, P., eds. 2002. Chartered Society of Physiotherapy. Rules of Professional Conduct, 2nd edn. London: CSP Butler, D. S. 2000. The Sensitive Nervous System. Adelaide: NOI Group Difabio, R. P. 1992. Efficacy of manuaJ therapy. Physical Therapy, 72, 853-864 Frank, c., Akeson, W. H., Woo, S. L- Y, Arniel, D. & Coutts, R. 1984. Physiological and therapeutic value of passive joint motion. Clinical Orthopaedics and Related Research, 185, 1 13-125
Gifford, 1. S. 1997. Pain. In Rehabilitation of Movement: Theoretical Basis of Clin ical Practice, ed. J. Pitt-Brooke, pp. 196-232. London: W. B. Saunders Higgs, J. & Jones, M. 2000. Clinical Reasoning in the Health Professions, 2nd edn. Oxford: Butterworth-Heinemann Hunter, G. 1994. SpeCific soft tissue mobilisation in the treatment of soft tissue lesions. Physiotherapy, 80, 1 5-21 Maitland, G. D. 1987. The Maitland Concept: assessment, examination and treatment by passive movement. In Physical Therapy of the Low Back, Vol 13, ed. 1. T. Twomey & J. R. Taylor, pp. 135-155. Edinburgh: Churchill Livingstone Maitland, G. D. 1991 . Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann
37
J
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MAITLAND'S PERIPH ERAL MANIPULATION
L Moore, A. & Petty, N. 2001 . Evidence based practice - getting a grip and find ing a balance [editorial]. Manual Therapy, 6, 195-196 Muncy, H. 2000. The challenge of change in practice. In Topical Issues in Pain 2, Biopsychosocial Assessment and Management, Relationships and Pain, ed. L. Gifford, pp. 37-54. Falmouth: CNS Press Pitt-Brooke, J., ed. 1997. Neuromuscular therapeutic techniques. In Rehabilitation of Movement: Theoretical Basis of CLinical Practice, pp. 361-399. London: W. B. Saunders Riddoch, J. & Lennon, C. 1991 . Evaluation of practice: the single case study approach. Physiotherapy Theon; and Practice, 7, 3-11 Rocabado, M. 1985. Arthrokinematics of the temporomandibular joints. In Clinical Dysfunction of the Head, Neck and Temporomandibular Joints: Pain and Dysfunction. New York: W. B. Saunders Sackett, D. L., Rosenburg, W. M. & Gray, J. A. 1996. Evidence based medicine: what it is and what it is not. BM], 312, 71-72 Sahrmann, S. A. 2001 . Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby Salter, R 1989. The biological concept of continuous passive motion in synovial joints: the first 18 years of basic
research and its clinical application. Clinical Orthopaedics and Related Research, 242, 1 2-25
Shacklock, M. 1995. Neurodynarnics. Physiotherapy, 81, 9-16 ShekeJJe, P. 1994. Spinal update, spinal manipulation. Spine, 19, 858-861 Sterling, M., Jull, G. & Wright, A. 2000. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. In The 7th Scientific Conference of the IFOMT in conjunction with the MPAA, International Federation of Orthopaedic Manipulative Therapists, ed. K. P. Singer. Perth, p. 166 Van Wingerden, B. A. M. 1995. Connective Tissue in Rehabilitation. Vaduz: Scirpo Verlag Waddell, G. 1998. The Back Pain Revolution. Edinburgh: Churchill Livingstone Williams, P. L. & Warwick, R, eds. 1980. Gray's Anatomy, 36th edn. London: Churchill Livingstone Wright, A. & Sluka, K. 2001. Non-pharmacological treatments for musculoskeletal pain. Clinical Journal of Pain, 17, 33-46 Zusman, M. 1986. Spinal manipulative therapy - a review of some proposed mechanisms and a new hypothesis. Australian Journal of Physiotherapy, 32, 89-99
39
Chapter
3
Communication and the therapeutic relationship
THIS CHAPTER INCLUDES: •
Key words for this chapter
•
Glossary of terms for this chapter
•
A review of the relevance of the therapeutic relationship in physiotherapy literature
•
•
Aspects of communication and
•
interaction
•
communication Communication techniques
•
The importance of active and passive listening
KEY WORDS
communication, interaction,
Verbal communication, non-verbal
therapeutic relationship, critical
GLOSSARY OF TERMS Collaborative goal setting - the process in which the physiotherapist defines desired outcomes of treatment with the patient, rather than for the patient. This is an ongoing process throughout all sessions. It includes goals of treatment, selection of interventions and parameters to assess treatment results. Communication - verbal and non-verbal communication: communication may be considered as a process of the exchange of messages, which need to be decoded. A message may contain various aspects: the content of the message, an appeal, an indication
Process of collaborative goal setting
Verbal and non-verbal
•
Shaping of interactions
•
Critical phases in the therapeutic process
•
Verbatim examples of various phases in the therapeutic process.
phases of the therapeutic process.
of the relationship to the person to
information with regard to
whom the message is addressed,
diagnosis or assessment.
and revealing something about the
Furthermore, skipping may impede
sender of the message (Schulz
the therapeutic relationship as the
von Thun
1981). Watzlawick (1969) - 'non
et ai's axiom
communication does not exist' -
patient may not understand the purpose of certain procedures. Immediate-response questions - in
indicates that non-verbal
various phases of the process of
communication as well as the
information gathering (initial
absence of words can be a strong
sessions, reassessment procedures)
message. Critical phases of the therapeutic
the physiotherapist may need to gently interrupt the patient with
process - throughout the overall
an interceding 'immediate
physiotherapy process there are
response' question to seek
some specific 'critical' phases in
clarification of the information
which particular information needs
given by the patient. This is
to be sought or given. Skipping
particularly essential during the
some of the critical phases may
subjective examination in the
have a consequence that the
initial session and in reassessment
physiotherapist misses relevant
procedures where 'statements of
40
M A ITLAN D'S P E R I P H E R A L M A N I P U LAT I O N
fact' need to b e converted into
listening skills to allow the
which the physiotherapist follows
comparisons.
development of a climate in
the patient's line of thought rather
Key phrases, key words, key gestures need attention throughout the whole physiotherapy process. If picked up and reacted upon, the
which the patient feels free to
than letting the physiotherapeutic
reveal any information which
procedures of subjective
seems relevant. technique which may be
important information in
employed by the physiotherapist
Communication and the conscious
assessment and reassessment
to guide the patient to an
development of a therapeutic
increased awareness with regard
relationship are considered
be indicative clues to the patient's
to use of the body, posture or
important elements to enhance a
world of thoughts, feelings and
elements of the individual illness
climate in which the patient can
emotions, which may be
experience. Often starts off with,
learn, develop trust and recover full
contributing factors to ongoing
'I see you doing .. .' or 'I hear you
disability due to pain.
saying ... . Paralleling - an important communication technique, in
As described in former editions of Maitland's work (Maitland 1986, 1991), well-developed communication skills are essential elements of the physiotherapy process. They serve several purposes: They aid the process of information gathering with regard to physiotherapy diagnosis, treatment planning and reassessment of results. They may serve to develop a deeper understanding of the patient's thoughts, beliefs and feelings with regard to the problem. This information assists in the assessment of psychosocial aspects which may hinder or enhance full recovery of movement functions. Empathic communication with the above mentioned objectives also enhances the development of a therapeutic relationship.
THERAPEUTIC RELATIONSHIP Based on changing insights on pain as a multidimen sional experience, the therapeutic relationship is con sidered to have increasing relevance in physiotherapy literature. It is debated that interpersonal communica tion, next to academic knowledge and technical expert ise, constitutes one of the cornerstones of the art of health professions (Gartland 1984a). Furthermore, it is considered that the physiotherapy process depends strongly on the interaction between the physio therapist and the patient, in which the relationship
function. Yellow flags - psychosocial risk
'
INTRODUCTION
•
from a personal relationship.
procedures. Furthermore, they may
needs to develop passive and active
•
Therapeutic relationship - distinct
physiotherapist may receive
Listening skills - the physiotherapist
•
examination prevail.
Mirroring - communication
factors, which may hinder the process to full recovery of function.
may be therapeutic in itself (Stone 1991). The World Confederation of Physical Therapy (1999) describes the interaction between patient and physiotherapist as an integral part of physiotherapy, which aims to achieve a mutual understanding. Interaction is seen as a 'pre requisite for a positive change in body awareness and movement behaviours that may promote health and wellbeing' (WPCT 1999, p. 9). The physiotherapist may be seen as a treatment modality next to the physical agents applied (Charmann 1989), in which all the phys iotherapist's mental, social, emotional, spiritual and physical resources need to be used to establish the best possible helping relationship (Pratt 1989). It is recom mended that every health. professional establishes a therapeutic relationship with a client-centred approach, with empathy, unconditional regard and genuineness (Rogers 1980). In particular, empathy and forms of self disclosure by the therapist are seen as important ele ments of a healing environment (Schwartzberg 1992) in which markedly empathic understanding may support patients to disclose their feelings and thoughts regarding the problem for which they are seeking the help of a clinician (Merry & Lusty 1993).
The physiotherapist's role in the therapeutic relationship It is recognized that within the therapeutic process a phYSiotherapist may take on a number of different roles: • •
curative prophylactic
Communication and the therapeutic relationship
• • •
palliative (KNGF 1998) educational (French et a11994, KNGF 1998) counselling (Lawler 1988).
In relation to counselling it is argued that physiother apists may often be involved in counselling situations, without being fully aware of it (Lawler 1988). The use of counselling skills may be considered as distinct from acting as a counsellor, the latter being a function of psychologists, social workers or psychiatrists (Burnard 1994). However, it is recommended that every clinician learns to use counselling skills within their framework of clinical practice (Horton & Bayne 1998). It appears that over the years of clinical experience physiotherapists view their roles with regard to patients differently. As junior physiotherapists they may consider themselves more in an expert, curative role, providing treatment from the perspective of their professional expertise, while more senior physiother apists seem to endeavour to meet patients' preferences of therapy (Mead 2000) and engage more in social interactions with the patients (Jensen et al 1990), thus considering themselves more in the role of a guide or counsellor. The positive effects of a therapeutic relationship are seen in: •
•
•
•
•
•
actively integrating a patient in the rehabilitation process (Mattingly & Gillette 1991) patient empowerment (Klaber Moffet & Richardson 1997) compliance with advice, instructions and exercises (Sluys et a11993) outcomes of treatment, such as increased self efficacy beliefs (Klaber Moffet & Richardson 1997) building up trust to reveal information which the patient may consider as discrediting (French 1988) trust to try certain fearful activities again or re-establishing self-confidence and wellbeing (Gartland 1984b).
Notwithstanding this, the therapeutic relationship is often seen as a non-specific effect of treatment, meet ing prejudice in research and being labelled as a placebo effect, which needs to be avoided (Van der Linden 1998). However, it is argued that each form of treatment in medicine knows placebo responses, which need to be investigated more deeply and used positively in therapeutic settings (Wall 1994). These placebo effects seem to be determined more by charac teristics of the clinician than by features of the patients, such as friendliness, reassurance, trustworthiness, showing concern, demonstrating expertise and the ability to establish a therapeutic relationship (Grant 1994).
Research and the therapeutic relationship In spite of an increasing number of publications, rela tively few physiotherapy texts seem to deal explicitly with the therapeutic relationship when compared with occupational therapy or nursing literature. A CINAHL database search over the period 1993-1998 under the key words 'patient-therapist relationship' and 'therapeutic relationship' was performed: 5 out of 38 entries, and 6 out of 150 entries, respectively, were published in physiotherapy-related journals. Nevertheless, the World Confederation of Physical Therapy in the Description of Physical Therapy (1999) declared the interaction with the patient as an integral part of physiotherapy practice, and the Chartered Society of Physiotherapy in Great Britain, in the third edition of its Standards of Physiotherapy Practice, emphasizes the relevance of a therapeutic rela tionship and communication as key components of the therapeutic process (Mead 2000). These viewpoints seem to be shared by the majority of physiotherapists in Sweden. In a study with primary qualitative research and consequently a questionnaire with Likert-type answers, it was concluded that the majority of physio therapists attributed many effects of the treatment to the therapeutic relationship and the patient's own resources rather than to the effects of treatment techniques alone (Stenmar & Nordholm 1997). It is recommended that within a therapeutic rela tionship patients need to be treated as equals and experts in their own right, and that their reports on pain need to be believed and acted upon. Opportunities need to be provided to communicate, to talk with and listen to the patients about their problems, needs and experiences. In addition, independence in choosing personal treatment goals and interventions within a process of setting goals with rather than for a patient needs to be encouraged (Mead 2000). Various studies have been undertaken with elem ents of the therapeutic relationship among patients and phYSiotherapists. In various surveys of patients it was concluded that patients appreciated positive regard and willingness to give information next to pro fessional skills and expertise (Kerssens et aI1995), com munication skills and explanations on their level of thinking about their problem, and treatment goals and effects as well as confidentiality with the information given (de Haan et al 1995). In a qualitative study on elements of quality of physiotherapy practice, patient groups regarded the ability to motivate people and educational capacities as essential aspects (Sim 1996).
The therapeutic relationship and physiotherapy education and practice Indications exist that various dimensions of the thera peutic relationship are neglected in physiotherapy
41
42
M A I T LA N D ' S P E R I P H E R A L M A N I P U LAT I O N
L education and practice. I n a qualitative study i n Great Britain among eight physiotherapists offering low back pain education it was concluded that only one participant followed a patient-centred approach, with active listening to the needs of the patients, while the remaining physiotherapists followed a therapist centred approach (Trede 2000). In a survey among physiotherapists in The Netherlands it was concluded that almost all physiotherapists felt that insufficient communication skills training had been given during their undergraduate education (Chin A Paw et aI1993). Furthermore, in a qualitative study the participants felt that aspects of dealing with intimacy during daily clinical encounters between patients and physiother apists have been neglected (Wiegant 1993). In a qualita tive study among clinical instructors of undergraduate physiotherapy students it was noted that the clinical supervisors preferred to give feedback to the students on technical skills rather than on social skills (Hayes et aI1999). This may have the consequence that some students will never learn about the relevance of the therapeutic relationship in the physiotherapy process and later will not make the elements of this relation ship explicit in their clinical reasoning processes. Often physiotherapists consider communication as a by-product in therapy and don't consider this as 'work' (Hengeveld 2000); for example, 'every time the patient attended she had so many questions that it cost 10 minutes of my treatment time and I could not start working with her'. A study with interviews of 34 recipients of physio therapy treatment showed that patients not only appre ciate the outcomes of care but also the process in which therapy has been delivered. The following elements were identified as key dimensions that contribute to patient satisfaction with physiotherapeutic treatment: •
•
•
•
•
In order to develop a fruitful therapeutic relation ship, well-developed communication skills and an awareness of some critical phases of the therapeutic process are essential.
COMMUNICATION AND INTERACTION -===-=--=----:::11.
Most people consider that communication between two people who speak the same language is simple, routine, automatic and uncomplicated. However, even in normal day-to-day communications there are many instances in which misunderstandings occur. Even if the same words are being lIsed, they may have dif ferent meanings to the individuals involved in the communication. Communication may be seen as a process of send ing messages, which have to be decoded by the receiver of these messages. A message may contain various aspects: the content of the message, an appeal, an indication of the relationship to the person to whom the message is addressed, and revealing something about the sender of the message (Schulz von Thun 1981). This follows some of the axioms on communica tion as defined by Watzlawick in which it is discussed that 'non-communication does not exist' - in other
professional and personal manner of the therapist (friendly, sympathetic, listening, respectful, skilled, thorough, inspiring confidence) explaining and teaching during each treatment (identifying the problem, guidance to self management, process of treatment, prognosis) how the treatment was consultative (patient involvement in the treatment process, responses to questions, responsiveness to self-help needs) the structure and time with the therapist (e.g. short waiting time, open access and enough time) the outcome (treatment effectiveness and gaining self-help strategies).
It is concluded that it is essential to establish expect ations, values and beliefs with regard to physiotherapy treatment in order to optimize patient satisfaction with the delivered treatment (May 2001).
Figure
3.1
One of the problems of communication.
Communication and the therapeutic relationship
words, communication always takes place, whether the participants are aware of it or not. Every communi cation bears aspects of content and relationship, and human communication follows digital and analogue modalities, the latter referring to verbal and non verbal communication, which ideally should occur congruently (Watzlawick et aI1969). Many errors in communication occur as a result of different understanding and interpretation as well as to the selection of words. The cartoon depicted in Figure 3.1 highlights some of the difficulties which may occur during verbal communication. The last three lines in the cartoon bear greatest significance. This could be saying, 'What I said was so badly worded that it did not express the thought that was in my mind', or it is possible that the receiver tuned in, or listened closely only to those parts of the message that fitted their own way of thinking, and ignored other parts that did not. It is also possible that the receiver's expectations or frame of mind altered their perception. The feedback loop of Figure 3.2 indicates some of the coding errors wh.ich may occur during a communi cation between a 'sender' and a 'receiver' of a message. Communication, as any other skill in clinical work, is an ability which can be learned and refined by con tinuous practice. Attention to one level of communica tion (e.g. content and meaning of words) can be practised step by step, until a high level of skill in uncovering meanings is developed. A good way of dis covering more about an individual style of interview ing and communication is to record it on video or audiotape. Play it back to yourself and to constructive peers and supervisors. The skill must be developed to a high level if a patient's problem is to be understood without any detail being missed. The learning of this skill requires patience, humility, clarity and constructive self-criticism. Words, phrases and intonation need to be chosen care fully when asking questions to avoid being misunder stood, and patients must be listened to carefully so that the meanings of tlle words they use are not misinter preted (Maitland 1986). Attention needs to be given not only to what is said, but also to how it is said (Main 2004), including a careful observation of the body language of the patient. The physiotherapist should not be critical of the way a patient presents. The very presentation itself is a message, needing to be decoded in the same way as the many other findings that the subjective and phys ical examinations reveal. Various elements may lead to misinterpretation of the severity of the patient's symp toms and! or disability. The various ways that a person may experience pain or limitation of activities may lead to different
expressions of pain behaviour. Some may seem stoic and do not appear to experience much distress, while others seem to suffer strongly and have high anxiety levels. The way people express pain, distress or suffer ing may be due to learning factors, including the fam ily and the culture in which the person has been brought up. If patients are not fluent in the language of the examiner, their non-verbal expression to explain what is being experienced may be more exaggerated from the perspective of the examiner. Some patients will comment only on the symptoms tllat remain and do not comment on other aspects of the symptoms or activity levels that may have improved. The skilled physiotherapist can seek the positive side of the symp tomatic changes rather than accepting the more nega tive approach of the patient. Overall, it is essential for the physiotherapist to develop an attitude of uncondi tional regard towards the patient and the situation, as suggested by Rogers (1980), even if the physiother apist does not fully understand the patient's behaviour and marulers with regard to pain and disability.
Aspects of communication Communication consists of various components: • •
verbal components non-verbal components, such as tone of voice, body posture and movements and so on.
It is important that the physiotherapist creates a setting in which a free flow of communication is possible, allow ing an uncomplicated exchange of information. Atten tion to the physical distance to the patient, not too far and not too close, often enhances the process of informa tion gathering. At times a gentle touch will allow a quicker exchange of information, for example when the physiotherapist would like to know which areas of the body are free of symptoms. The physiotherapist may gently touch, for example, the knee of a patient in order to interrupt their somewhat garrulous dialogue, in order to become able to highlight an important aspect of tlle information given or to seek further clarification. Congruence of verbal and non-verbal communica tion is essential. Eye contact is important, as is a safe environment in which not too many outside disturb ances hinder the establishing of an atmosphere in which patients can develop trust to disclose information which they think might be compromising. It is important that the physiotherapist pays attention not only to what is said, but also to how it is said. Often tI1e body posture or the intonation of the voice or certain key words and phrases give indications of the individual illness experience, especially if certain words are used which may have a more emotional content (e.g. 'it is all
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M A ITLA N D'S P E R I P H E R A L M A N I P U LAT I O N
1st process The reasoning behind the question which is to be asked The fundamental error that lies behind much poor questioning is having insufficient theoretical and clinical Error
knowledge to guide the precise information required from a patient
, 2nd process
3rd process
Wording the question The error occurs when the question asked does not clearly ask what the physiotherapist needs to know
r+
Hearing and understanding the questions Two errors can occur at this stage:
1. A word or words may be used which the patient does not understand 2. What the patient hears may be biased away from
Error
what he should have heard
,
Error
4th process Considering the repty Because the patient has particular thoughts about his complaint, he may assure different reasons for the question from those of the physiotherapist. Also his memory of facts which are involved in answering the question may be incomplete or inaccurate
�
6th process
5th process
Hearing and understanding the words used in the
PUlling the answer Into words
patients answer Patients may use descriptive words which are difficult to understand, particularly when describing bizarre symptoms. The error lies in assuming the meaning of them rather than asking questions to be certain Error
of the meaning
, 7th process tnterpreting the answer Because the physiotherapist does not have the patient's symptoms herself, she has to interpret the answer in the light of her own experiences (including her experiences with other patients). The interpretation may be wrong
Error
if the answer is not clarified
, 8th process Relating the answer to the question If the phYSiotherapist accepts the patient's answer as providing all the information, when the fact it does not, the subsequent examination will be open to Error
major errors
, 9th process Determining the next question If there was insufficient knowledge on which to base the first question, irrespective of the accuracy of the patient's answer, the basis for the second question must also be in error If there has been no error in any of the preceding
Error
eight processes there should be no error in this 9th process
Figure
3.2
Feedback loop.
Error
To translate thoughts related to answering the question
I+-
into words is even more difficult for the patient than for the physiotherapist because of the comparative lack of experience Error
Communication and the therapeutic relationship
very terrible'). These may be clues to the patient's world of thoughts, feelings and emotions, which may be con tributing factors to ongoing disability due to pain (Kendall et al1997). As expressed in Chapter 5, attention to these aspects often allows the physiotherapist to perform a psychosocial assessment as an integral part of the overall physiotherapy-specific assessment. As pointed out in the chapters on assessment and examination (Chapters 5 and 6), many details are asked in order to be able to make a diagnosis of the movement disorder and its impact on the patient's life. Critics may say that the patient will not be able to provide all this information. However, it has long been a principle of the Maitland Concept that the 'body has the capacity to inform'. If the phYSiotherapist carefully shapes the inter view, pays attention to details such as selection of words and body language and explains regularly why certain questions or interventions are necessary, the patient will learn what information is of special relevance to the physiotherapist and pay attention to this.
Shaping of interactions During the overall series of treatment, as well as in each session, it is important that the physiotherapist shapes the interaction deliberately, if a conscious nur turing of the therapeutic relationship seems necessary. As in other cOlmselling situations, each series of therapy, as well as each treatment session, knows three phases of interaction (Brioschi 1998): •
•
InitiaL phase a 'joining' between physiotherapist and patient takes place on a more personal level in order to establish a first contact; personal expect ations are established; the patient's questions may be addressed; the speCific objectives of physio therapy or of the session are explained; the spe cific setting is clarified (e.g. number of sessions, treatment in an open or closed room). The first subjective and physical examinations or the sub jective reassessment takes place. It is essential that in this phase the (ongoing) process of collabora tive goal setting has started. -
MiddLe phase - working on the treatment objectives and using interventions in a collaborative way; regular reassessment to confirm the positive effects of the selected treatment interventions. It is import ant that all aspects of goal setting, selection of inter ventions and reassessment parameters are defined in a collaborative problem-solving process between the physiotherapist and the patient.
•
End phase of the session or of the treatment series summary; attention to the patient's questions; recommendations, instructions or self-management
strategies including reassessment; addreSSing of organizational aspects. Often it is very useful to ask the patient to reflect on what has been particularly useful in the current treatment session or series and what has been learned so far. Often both the information and the end phase (includ ing the final analytical assessment in the last sessions of the treatment series) seem to be neglected, mostly due to lack of time. However, once the more explicit procedures of the session are finished, towards the end of the session the patient often reveals information on the individual illness experience which may be highly essential for the therapy. The following example high lights this aspect. A 72-year-old lady presents to the physiotherapist with a hip problem. Joint mobilizations in lying and muscle recruitment exercises in sitting and standing are performed. At the end of the session, when saying goodbye, the lady tells the physiotherapist that she was going to visit her daughter in another town. However, she was not confident in getting on a bus, as the steps were so high and the drivers would move off too quickly before she was even seated. On the levels of disability and activity resources as defined by the
InternationaL Classification of Functioning, Disability and Health (WHO 2001), it was more relevant to redefine goals of treatment on activity and participation levels and for the patient to practise actually walking to and finding trust on entering the bus, rather than working solely on the functional impairments in the physio therapy practice. This information was not given in the initial examination session, in spite of deliberate ques tioning by the phYSiotherapist. Shaping of a therapeutic climate: listening and communication In order to stimulate a safe environment in which a free flow of information can take place, the develop ment of listening skills is essential. Therapists may well hear what they expect to hear rather than listen ing to the words the patient uses. The following quota tion may serve to underline this principle:
Listening is itself, of course, an art: that is where it differs from mereLy hearing. Hearing is passive; listening is active. Hearing is voLuntary, Listening demands attention. Hearing is natural, Listening is an acquired discipLine. The Age (1982) It is essential to develop the skills of active and passive listening: •
Passive listening means showing that the therapist is listening, with body posture directed towards
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L
•
the patient, maintaining eye contact, and allowing the patient to finish speaking. Active listening encourages patients to tell their story and allows the therapist to seek further clarification.
Active listening may include clarifying questions such as 'Could you tell me more about this?', repetition and summary of relevant information such as 'If I have understood you correctly, you would like to be able to play tennis again and find more trust in riding your bicycle?', or asking questions with regard to the per sonal illness experience, for example, 'How do you feel about your back hurting for so long?' With active and passive listening skills the therapist can show that they have understood the patient. In order to shape a therapeutic climate of uncon ditional regard (Rogers 1980), it is essential that the responses and reactions of the therapist are non judgemental and neutral. Irony, playing the experience of the patient down, talking too much of oneself, giving maxims, threatening ('if you won't do this then your back will never recuperate') or just lack of time may jeopardize the development of the therapeutic relationship (Keel 1996, quoted in Brioschi 1998). If patients reveal personal information, it is essen tial that they are given the freedom to talk as much about it as they feel necessary. At all times the physio therapist should avoid forcing patients to reveal per sonal information which they would rather have kept to themselves. This may happen if the physiotherapist asks exploratory questions too aggressively. Some excellent publications with regard to 'sensitive prac tice' have been published, and are recommended for further exploration of this issue (Schachter et aI1999). Giving advice too quickly, offering a single solution, talking someone into a decision or even commanding may hinder the process of activating the patient's own resources in the problem-solving process. If pOSSible, it is better to guide people by asking questions rather than telling them what to do. This is particularly essen tial in the process of collaborative goal setting in which the patient is actively integrated in defining treatment objectives. In this process it is important to define treatment objectives on activity and participa tion levels (WHO 2001) which are meaningful to the patient. Too frequently it seems that the physiother apist is directive in the definition of treatment goals and in the selection of interventions (Trede 2000). Ideally the therapist may offer various interventions from the perspective of professional expertise to reach the agreed goals of treatment, and the decision is left to the patient to decide which solution may be best for the problem.
Communication techniques Communication is both a skill and an art. Various com munication techniques may be employed to enhance the flow of information and the development of the therapeutic relationship. •
•
•
•
•
•
Style of questions: - Open questions (e.g. 'What is the reason for your visit?') - Questions with aim (e.g. 'Could you describe your dizziness more?', 'What do you mean by pinched nerves?') - Half-open questions - as suggested in the subjective examination. The questions are posed with an aim, but they leave the patient the freedom to answer spontaneously. These questions often start with hmo, when, what, where (e.g. 'How did it start?', 'When do you feel it most?', 'What impact does it have on your daily life?', 'Where do you feel it at night?') - Alternative questions -leave the patient a limited choice of responses (e.g. 'Is the pain only in your back or does it also radiate to your leg?') - Closed questions -can only be answered with yes or no (e.g. 'Has the pain got any better?') - Suggestive questions -leave the patient little pos sibility for self-expression (e.g. 'But you are better, aren't you?') It may be necessary to employ a mixture of ques tion styles in the process of gathering information. Half-open questions and questions with aim may provide information concerning biomedical and physiotherapy diagnosis; frequently, however, they are too restricting if the physiotherapist wants to get an understanding of the patient's thoughts, feelings and beliefs with regard to the individual ill ness experience and psychosocial assessment. Such questions may provoke answers of social desirabil ity or the patient may not reveal what is actually being experienced. Modulation of the voice and body language - as described before. Summarizing of information - in the initial phase this technique is often useful during the subjective examination in various stages: after the completion of the main problem and 'body chart', after the establishment of the behaviour of symptoms, after completion of the history and as a summary of the subjective and physical examinations. Mirroring -in which the physiotherapist neutrally reports what is observed or heard from the patient. (Short) pauses before asking a question or giving an answer. Repetition (with a question) of key words or phrases.
47
Communication and the therapeutic relationship
Probably the first requirement during interviews with patients is that the physiotherapist should retain control of the interview. Even if the physiotherapist decides to employ forms of 'narrative clinical reasoning' rather than procedural clinical reasoning (Chapter 5), it is necessary that the physiotherapist keeps an overview of the indi vidual story of the patient and the given information which is particularly relevant to establish a diagnosis of a movement disorder and its contributing factors. It is essential to use the patient's language whenever possible, as this makes things that are said or asked much clearer and easier to understand. A versatile physiotherapist can develop various ways to stop or interrupt a more garrulous patient, by making statements such as 'I was interested to hear about X, could you tell me more?' Another possibility may be gently touching the patient's knee before stat ing, 'I would like to know more about this'. Interposing a question at a volume slightly higher than the patient's or with the use of non-verbal techniques such as rais ing a hand, making a note, or touching a knee, tends to interrupt the chain of thought and this may be employed if the spontaneous information does not seem to be forthcoming. More reticent patients need to be told kindly that it seems they find it hard to talk about their complaints but that it is necessary for them to do so. They should be reassured that they are not complaining, but informing. The following strategies are important to keep in mind during the interview: • • •
• • •
Speak slowly. Speak deliberately. Use the patient's language and wording, if possible. Keep questions short. Ask only one question at a time. Pose the questions in such a manner that as much as possible spontaneous information can be given (see above).
Paralleling When a patient is talking about an aspect of their prob lem, their mind is running along a specific line of thought. It is likely that the patient could have more than one point they wish to express. To interrupt the patient may make them lose their place in their story. Therefore, unless the physiotherapist is in danger of getting confused, the patient should not be stopped if at all possible while the therapist follows the patient's line of thought. However, a novice in the field may rather first practice the basic procedures of inter viewing, as paralleling is a skill which is learned by
experience. Paralleling may be a time-consuming pro cedure if the patient starts off with a long history of, for example, 20 years. It may then be useful to interrupt and ask the patient what the problem is now and why help is being sought from the physiotherapist now and from then on the physiotherapist may use the technique of paralleling. Paralleling means that, from the procedural point of view the physiotherapist would like to get information (e.g. about the localization of symptoms), whereas the patient is talking about the behaviour of the symp toms. However, using 'paralleling' techniques does not mean that the physiotherapist should let the patient talk on without seeking clarification or using the above-mentioned communication techniques.
-
Immediate-response questions At times the employment of immediate-response questions is essential. If during the first consultation a patient gives important information with regard to the planning of physical examination and treatment, immediate-response questions may be needed. Example: Patient: 'I feel it mostly with quick movements.' Therapist: 'Quick movements of what?' Following the patient's answer: 'In what direction?', or: 'Are you able to show me that quick movement now?' The informa tion on the area of the movement and the direction of the movement may be decisive in the selection of treatment techniques. During subsequent treatments in the reassessment phases, the physiotherapist is in a process with the patient of comparing changes in the symptoms and signs. Frequently, however, the patient may give infor mation which is a 'statement of fact'. The patient may say, 'I had pain in my back while watching football on television'. This is a statement of fact and is of no value as an assessment, unless it is known what would have happened during 'watching television' before starting treatment. This statement demands an immediate response question: 'How would you compare this with, for example, 3 weeks ago, when we first started treat ment?' The patient may respond that in fact 3 weeks ago he was not able to watch television at all, as the pain in his back was too limiting. Using immediate-response questions during this phase of reassessment prevents time being wasted and valuable information being lost. If the physiotherapist employs this technique kindly but consistently in the first few treatment sessions, the patient may learn to compare changes in his condition rather than to express statements of fact. At reassess ment, convert statements of fact into comparisons!
Furthermore, immediate-response questions may be needed with non-verbal responses. There are many
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L examples i n which the examiner must recognize a non verbal response either to a question or to an examin ation movement. The physiotherapist must qualify such expressions. For example, in response to a ques tion the patient may respond simply by a wrinkle of the nose. The immediate-response question, in combin ation with a mirroring technique may be: 'I see that you wrinkled your nose - that doesn't look too good. Do you mean that it has been worse?', etc. Key words and phrases During patients' discourses they will frequently make a statement or use words that could have great significance - the patient may not realize it, but the therapist must latch onto it while the patient's thoughts are moving along the chosen path. The physiother apist could use it either immediately by interjecting or by waiting until the patient has finished. For example, the therapist might say:
Q A
'You just mentioned your mother's birthday - what does that relate to?' 'Well, I can remember that it was on my mother 's birthday that I was first aware of discomiort in my shoulder when I reached across the table to pick up her birthday cake.'
By instantly making use of the patient's train of thought (paralleling) the development of the progres sive history of the patient's shoulder pain is easier to determine for both the therapist and the patient, because, in fact, the patient's mind is clearly back at the birthday party. As another example, having asked the question at subjective reassessment procedures, 'How have you been?', the patient may respond in a general and rather uninformative way. However, during subsequent state ments the patient may include, for example, the word 'Monday'. This may mean something to the patient and therefore it is often effective to use it and ask, 'What was it about Monday?', or 'What happened on Monday?' Bias It is relatively easy to fall into the trap of asking a ques tion in such a way that the patient is influenced to answer in a particular way. For example, the therapist may wish to know whether the last two sessions have caused any change in the patient's symptoms or activ ity levels. The question can be asked in various ways: 1.
'Do you feel that the last two treatments have helped you?' 2. 'Has there been any change in your symptoms as a result of the last two treatments?'
3.
'Have the last two treatments made you any worse in any way?'
The first and third questions are posed with aim, never theless they are suggestive. The first question, however, is biased in such a way that it may push the patient towards replying with 'yes'. The second and third questions are acceptable, as the second question has no specific bias and the third question biases the patient away from a favourable answer. Both questions allow the patient to give any spontaneous answer, even if the therapist is hoping that there has been some favourable change.
Purpose of the questions and assuming Purpose of the questions In efficient information gathering it is essential for the physiotherapist to be aware of the purpose of the questions - no question should be asked without an understanding of the basic information that can be gained (see Chapters 5 and 6). For beginners in the field it is essential to know which questions may support the generation of which specific hypotheses. Before asking a question it is vital for the physio therapist to be clear about several things: 1. 2. 3. 4.
What information is required and why. What is the best possible way to word the question. Which different answers might be forthcoming. How the possible reply to this question might influence planning ahead for the next question.
A mistake that often occurs with trainee manipulative physiotherapists is the accepting of an answer as being adequate when in fact it is only vaguely informative, incomplete or of insufficient depth. The reason for accepting an inadequate answer is usually that trainee phYSiotherapists do not clearly understand why they are asking the question and therefore do not know the number of separate answers they must. hear to meet the requirements of the question. The same reason can lead to another error: allowing a line of thought to be diverted by the patient, usually without realizing it.
Assuming If a patient says that pain is 'constant', it is wrong to assume that this means constant throughout the day and night. The patient may mean that, when the pain is present, it is constant, but not all day long. It is import ant to check the more exact meaning: is it 'steady' or 'unchanging in degree', 'constant in location' or 'constant in time'?
Communication and the therapeutic relationship
Assuming may lead to one of the major errors in clin ical reasoning processes: misinterpretation of informa tion, leading to overemphasis or blinding out of certain information. Therefore it is well worth remembering: never assume anything!
Pain and activity levels Sometimes the Maitland Concept is criticized for put ting too much focus on the pain experience and some may state that 'talking about pain causes some people to develop more pain'. If in examination and reassessment procedures the physiotherapist focuses solely on the pain sensation and omits to seek information on the level of activities, bias towards the pain sensation may occur and some patients may be influenced to focus mainly on their pain experience. It may then seem that they develop an increased bodily awareness and become more pro tective towards movements which may be painful. It is therefore essential that the physiotherapist estab lishes a balanced image of the pain including the con comitant activity linutations and resources. Sometimes the pain experience does not seem to improve and leaves the patient and physiotherapist with the impres sion that 'nothing helps'. However, if the level of activ ity normalizes and the patient may successfully employ some self-management strategies once the pain is expe rienced again, both the patient and physiotherapist may become aware of positive changes, if they look for them. Some physiotherapists prefer, with some patients, not to talk about pain and to focus only on the level of activity and may even make a verbal contract with the patient not to talk about pain any more and only about function (Hengeveld 2000). However, often this is not of much help, as it denies one of the major complaints for which the patient is seeking therapy, and in fact it denies the most important personal experience of the patient. Nevertheless, .in such cases it may be useful to use metaphors for the pain experience, wellbeing and activity levels. For example, rather than asking, 'How is yom pain?', the therapist may ask, 'What does yom body tell you now in comparison with before?' or, 'If the pain is like a high wave on the ocean in a storm, how is the wave now in comparison with before?' On the other hand, some patients prefer to focus on their activities rather than on the pain sensation alone. The following statement was once overheard in a clin ical situation:
Patient to physiotherapist: 'You aLways taLk about the pain. However it is Like having a filling of a tooth - if I give it attention, I wiLL notice it. However I still am able to eat normally with it.'
thus indicating that, to the patient, it is important to be able to function fully and that he will accept some degree of discomfort.
THE PROCESS O F CO L LA BO RATIVE GOAL SETTING As stated earlier, it is recommended that within a thera peutic relationship patients need to be treated as equals and experts in their own right. Within this practice following a process of collaborative goal setting is recommended (Mead 2000). There are indications that compliance with the rec ommendations, instructions and exercises may increase if treatment objectives are defined in a collab orative rather than a directive way (Riolo 1993, Sluys et a1 1993, Bassett & Petrie 1997). It is essential to consider collaborative goal setting as a process throughout all treatment sessions rather than a single moment at the beginning of the treatment series. In fact, ongoing information and goal setting may be considered essential elements of the process of informed consent. Various agreements between the physiotherapist and patient may be made in the process of collabora tive goal setting: •
•
•
•
Initially the physiotherapist and patient need to define treatment objectives collaboratively. Additionally, the parameters to monitor treatment results may be defined in a collaborative way. The physiotherapist and patient need to collaborate on the selection of interventions to achieve the desired outcomes. In situations where 'sensitive practice' seems especially relevant, some patients may need to be given the choice of a male or a female physiotherapist or may express their preference regarding a more open or an enclosed treatment room (Schachter et aI 1999).
Frequently, physiotherapists may ask a patient at the end of the subjective examination what would be the goal of treatment. Often the response will be that the patient would like to have less pain and no further clarification of this objective takes place. In some cases this approach may be too superficial, especially if the prognosis is that diminution of pain intensity and fre quency may not be easily achieved. This may be the case in certain chronic pain states or where secondary prevention of chronic disability seems necessary. Patients commonly state that their goal of treatment is 'having less pain'; however, after being asked some clarifying questions it often transpires that they wish to find more
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L control over their wellbeing with regard to pain, in order to be able to perform certain activities again. In the initial session during subjective examination various stages occur in which collaborative goal set ting may take place by the communication technique of summarizing: •
•
• •
after establishment of the main problem and the areas in which the patient may feel the symptoms after the establishment of the 24-hour behaviour of symptoms, activity levels and coping strategies after establishment of the history after completion of the physical examination (at this stage it is essential to establish treatment objectives collaboratively, not only in the reduction of pain, but also to define clear goals on the levels of activity which need to be improved and in which circumstances the patient may need self management strategies to increase control over wellbeing and pain).
The relatively detailed process of collaborative goal setting needs to be continued during each session in its initial phase. It is essential to clarify if the earlier agreed goals are still to be followed up. If pOSSible, it is useful to explain to the patient the diverse treatment options on how the goals may be achieved and then let the patient make the choice of the interventions. Another phase of collaborative goal setting takes place in later stages during retrospective assessment procedures. In this phase a reconsideration of treatment objectives is often necessary. Initially the physiother apist and patient may have agreed to work on improve ment of pain, pain control with self-management strategies, educational strategies with regard to pain and movement, and to treat impairments of local func tions, such as pain-free joint movement and muscular recruitment. In later stages it is essential to establish goals with regard to activities which are meaningful for the patient. If a patient is able to return to work after a certain period of sick leave, it is important to know about those activities which the patient seems most con cerned about and where the patient expects to develop symptoms again. For example, an electrician who needs to kneel down in order to perform a task close to the floor may be afraid that in this case his back may start to hurt again. It may be necessary to include this activity in the training programme in combination with simple self-management strategies which can be employed immediately in the work-place. This phase of retrospective assessment, including a prospective assessment with redefinition of treat ment objectives on activity and participation levels, is considered one of the most important phases of the
rehabilitation of patients with movement disorders (Maitland 1986). To summarize, the process of collaborative goal setting should include the following aspects (Brioschi 1998): • •
•
•
the reason for referral to physiotherapy the patient's definition of the problem, including goals and expectations clarification of questions with regard to setting, frequency and duration of treatment hypotheses and summary of findings of the physiotherapist, and clarification of the possibilities and limitations of the phYSiotherapist,
resulting in agreements, collaborative goal definitions, and a verbal or sometimes written treatment contract.
CRITICAL PHASES O F THE THERAPEUTIC PRO CESS In order to shape the therapeutic process optimally, special consideration needs to be given to the informa tion which is given to the patient and sought by the phYSiotherapist in specific phases of the therapeutic process. In fact, the educational task of the physiother apist may start at the beginning of the first session in which the expectations of the patient towards physio therapy need to be clarified. If some of these critical phases are skipped it is pos sible that the process of actively integrating the patient into the therapeutic process is impeded. Attention to these phases supports the development of mutual trust and understanding, enhances the therapeutic relationship and aids in the development of a treat ment plan. In these various stages regular interven tions of collaborative goal setting should take place, clarifying step-by-step: • • •
the goals of treatment what possibilities exist to achieve these goals where certain limitations may be present.
It is essential that the physiotl1erapist not only points out the possibilities of treatment, but also indicates, carefully and diplomatically, the possible limitations with regard to achievable goals. This is particularly essential in those cases where the patient seems to have almost unrealistic expectations of the physiotherapist, which it may not be possible to fulfil. Particularly with patients with chronic disability due to pain, it is fre quently necessary to point out that the physiotherapy interventions may not necessarily be able to reduce the pain, but that the physiotherapist can work with them
Communication and the therapeutic relationship
to find ways to establish more control over their well being and to normalize the level of activities which are meaningful to them. In general it is useful to pay attention to these critical phases in order to 'keep the patient on board'. It is stated that novices in the field tend to be more mechan ical in their interactions with patients in which their own procedures seem to prevail above the direct inter actions with the patient (Jensen et al 1990, 1992; Thomson et al 1997). However, it is essential that the patient understands the scope and limitations of physiotherapy as a movement science as well as the reason for certain questions and test procedures. At times it can be observed in supervision or examination situations that physiotherapists appear to be preoccu pied with their procedures of examination, treatment, recording and reassessment and seem to forget to explain to patients what they are doing and why. It may happen in such cases that the patient is not able to distinguish between a reassessment and a treatment procedure. Furthermore, by paying attention to the information of some critical phases, the physiotherapist may address some 'yellow flags', which may hinder the full recovery of movement function. Secondary preven tion of chronic disability may start with the welcoming and initial assessment of the patient's problem. The critical phases of the therapeutic process (Fig . 3.3) need specific consideration with regard to providing and gathering of information.
Welcoming and information phase After some 'joining' remarks to help the patient feel at ease as a first step towards development of a therapeutic relationship, it is important to inform the patient in
•
I
Referral
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t
examination
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I am aware that your doctor has seen you and diagnosed your probLem as osteoarthritis of the hip and I have this diagnosis in the back of my head. However, my specific task as a physiotherapist is to examine and treat your movement functions. Maybe you have certain habits in your daily life, or you may have stiffjoints or muscles which react too Late. I need to ask some questions about this and I would like to look in more detail at your movements. Often when these movements improve, the pain of the osteoarthritis may aLso normalize. Is this what you yourself expected as a treatment for your probLem ? Starting a session in this manner often prevents the patient from developing irritation that the physiother apist starts off with an examination, as this may have already been done by the referring doctor. Further more, the patient may learn immediately that the physiotherapist follows a somewhat different perspec tive to problem-solving processes than a medical doc tor. Too often patients do not understand that each member in an interdisciplinary team follows a unique frame of reference which is specific to their profession (Kleinmann 1988).
t t t
Subjective
elcome/info
this phase about the specific movement paradigm of the physiotherapy profession - the 'clinical side' of the brick wall analogy of the Maitland Concept. The patient may have different beliefs or paradigms from the physiotherapist as to the causes of the problem and the optimum treatment strategies, which may create an implicit conflict situation if not clarified in time. The physiotherapist may explain this to the patient in the following way:
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Planning physical examination Physical examination
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Reassessments
Reflection on initial examination Treatment plan
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t t
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•
Final analytical assessment
Retrospective assessments Prospective assessment
Goals and interventions Figure
3.3
Critical phases i n the therapeutic process in which specific co nsid eration is given to the i n formation process.
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L Some questions with regard t o yellow flags may also be addressed with this information (Kendall et al 1997, Main 2004): • •
•
Is the patient expecting physiotherapy to help? Which beliefs does the patient have with regard to movement if something hurts? Does the patient feel that the problem has not been examined enough?
It is essential to be aware of certain key remarks indi cating these points, for example, 'Well, the doctor did not even bother to make an x-ray . . . '. If these points are addressed early enough in the treatment series, some patients may start to develop trust and carefully embark on a treatment, which they initially may have approached sceptically, especially if they have already had various encounters with many different health care practitioners (Main & Spanswick 2000).
Subjective examination The subjective examination serves several purposes as described in the chapters on assessment and examina tion (Chapters 5 and 6). It is essential to pay attention not only to what is said but also to how things are said by the patient. Key words, gestures and phrases may open a window to the world of the individual illness experience, which may be decisive in treatment planning. Furthermore, the physiotherapist needs to ensure that the patient understands the purpose of the questions - be they a baseline for comparison of treat ment results in later reassessment procedures or indicative of the physiotherapy diagnosis, including precautions and contraindications. Most essential are the various steps in collaborative goal setting, which preferably take place throughout the overall process of subjective examination. With information on the main problem and the 'body chart', the physiotherapist may develop a first general idea of the treatment objectives; with increasing information throughout the whole examination, this image of the various treatment goals should become more and more refined.
treatment objectives on which the patient and the physiotherapist have agreed so far. Furthermore, it is essential to explain to the patient the purpose of the physical examination.
Physical examination In order to integrate the patient actively in this phase of examination, it is recommended that the physio therapist explains why certain test procedures are per formed and to teach the patient to become aware of the various parameters which are relevant from the physiotherapist's perspective - for example, it may be important during active test movements to educate the patient that the physiotherapist is interested not only in any symptom the patient may feel but also in the range of motion, the quality of the movement and the trust of the patient in the particular movement test. During palpation sessions and the examination of accessory movements, the patient should be encour aged not only to describe any pain but also any sensa tions of stiffness at one level in the spine in comparison with an adjacent level. This is a procedure which requires highly developed communication skills; however, it can be an important phase in the training of the perception of the patient. Furthermore, it is recommended that physiotherap ists inform patients not only about those tests which serve as a reassessment parameter but also about the test movements that have been judged to be normal. Frequently it appears that physiotherapists are more likely to be deficit oriented in their examinations; however, to many patients it is a relief to hear from the therapist which movements and tests are considered to be normal. Sometimes patients may indicate their anxiousness with certain test procedures (e.g. SLR) based on earlier experiences. In such cases it is essential to negotiate directly with the patient how far the physiotherapist will be allowed to move the limb. In fact, 'trust to move' may become an important measurable and achievable parameter, which may indicate the first beneficial changes in the condition of the patient.
Ending a session Planning of the physical examination The planning phase between the subjective and the physical examination is crucial from various perspec tives. The main objective of this phase is the planning of the physical examination in its sequence and dosage of the examination procedures. However, it is import ant to surrunarize the relevant points of the subjective examination first and then to describe the preliminary
Sufficient time needs to be planned for the ending of a session. On the one hand the physiotherapist may instruct the patient about how to observe and compare the possible changes in symptoms and activity levels. Furthermore, the therapist may need to warn the patient of a possible exacerbation of symptoms in cer tain circumstances. A repetition of the first instruc tions, recommendations or self-management strategies
Communication and the therapeutic relationship
may be necessary in order to enhance short-term com pliance (Hengeveld 2003). As described in Shaping of interactions above, attention needs to be given to unexpected key remarks of the patient as these may be indicative of the individual illness experience and relevant treatment objectives .
Evaluation and reflection of the first session. including treatment pl anning This phase includes summarizing relevant subjective ' and physical examination findings, making hypoth eses explicit, outlining the next step in the process of collaborative goal setting for treatment and, if possible, collaboratively defining the subjective and physical reassessment parameters. If the physiotherapist is confronted with a recognizable clinical presentation, this phase may have occurred partially already during the examination process ('reflection in action'). How ever, in more complicated presentations or in new situations the physiotherapist may need more time to reflect on this phase after the first session ('reflection on action') before explaining the physiotherapy view points to the patient and suggesting a treatment plan (Schon 1983). In particular, trainees and novices in the field need to be given sufficient time to reflect before entering the next treatment session in order to develop comprehensive reflective skills (Alsop & Ryan 1996). The completion of a clinical reasoning form may aid the learning process of the students in the various phases of the therapeutic process.
Reassessments As stated earlier, it is essential that patients are able to recognize reassessment procedures as such and do not confuse them with a whole set of procedures in which they may not be able to distinguish between treatment and evaluation . Education of patients may be needed to observe possible changes in terms of comparisons, rather than statements of fact. Cognitive reinforcement at the end of a reassessment procedure may be helpful to support the learning processes of both the patient and the physiotherapist. If the physiotherapist employs educational strategies it may be necessary to perform a reassessment on this cognitive goal as well. Often it is useful to integrate questions with regard to self management strategies in the opening phase of each session during the subjective reassessments. However, from a cognitive-behavioural perspective the way a patient is asked if they are capable of doing their exer cises and to evaluate the effects of these can be decisive in the development of understanding and compliance.
Retrospective assessment In an earlier edition of Maitland's work it was stated that retrospective assessments are crucial aspects of the Concept . In retrospective assessment in particular, the physiotherapist evaluates patients' awareness of changes to their symptoms as one of the most important elements of evaluation. The only way to get this infor mation is with skills in communication and awareness of possible changes in symptoms, signs, activity levels and illness behaviour. The physiotherapist evaluates the results of the treatment so far, including the effects of self-management strategies. In this phase it is essen tial to (re)define collaboratively with the patient the treatment objectives for the next phase of treatment, preferably on levels of activity and participation (WHO 2001) ('prospective assessment') and leading to an optimum state of wellbeing with regard to move ment functions (Chapters 4 and 5).
Final analytical assessment This phase includes the reflection of the overall thera peutic process, when assessment is made of which interventions have led to which results. Often it is use ful to reflect with the patient what has been learned so far. In order to enhance long-term compliance the phys iotherapist may anticipate collaboratively with the patient on possible future difficulties in activities or work and which self-management interventions may be useful if there is any recurrence (Sluys et aI 1993).
VERBATIM EXAM P LES Although communication with a patient is a two-way affair, the main responsibility for its effectiveness lies with the therapist rather than with the patient. The therapist should be thinking of three things (Maitland 1991): I should make every effort to be as sure as is possible that I understand what the patient is trying to tell me. 2. I should be ready to recognize any gaps in the patient's communication, which I should endeavour to fill by asking appropriate questions. 3. I should make use of every possible opportunity to utilize my own non-verbal expressions to show my understanding and concern for the patient and his plight . 1.
The following verbatim examples in this text are used to provide some guidelines which will, it is hoped,
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help the physiotherapist t o achieve the depth, accur acy and refinement required for good assessment and treatment. The guidelines should not be interpreted as preach ing to the ignorant - they are given to underline the essence of careful and precise communication as an integral part of overall physiotherapy practice.
Welcoming and information phase As described above, the welcoming and information phase may be an essential stage to 'get a patient on board' in the physiotherapy process. This phase needs an explanation on the paradigms in physiotherapy, which can be understood easily by the patient. It is essential to find out if the patient can be motivated to physiotherapy and to develop trust in what is lying ahead in the therapy sessions. In this phase it is also important to find out if a patient has already consulted a number of different specialists in the medical field for the problem. Often the patient may have received various opinions and viewpoints and is left confused, especially if they seem to have a more externalized locus of control with regard to their state of health (Rotter 1966, Harkapaa et a1 1989, Keogh & Cochrane 2002, Roberts et al 2002). A patient may indicate by certain key phrases the expectation of a single cure according to the biomedical model, whereas the physiotherapist expects to treat the patient according to a movement paradigm in which self-management strategies may play an important role: 'I have seen so many specialists - everybody says something different. Why don't they find out what is wrong with me and then do something about it?' There are many ways to respond to such a state ment but it is crucial that such a key remark is not ignored. The phYSiotherapist may respond in various ways, for example:
Q Q
'What would you think that they would need to do about it?' 'Now you have come to me - there is a chance that I might also have a different opinion, like all the others. How would you feel about that?'
Initial assessment: subjective examination As stated above, in this phase it is vital to concentrate on both the patient's actual words and how they are deliv ered. Furthermore, during the overall process of subjec tive examination the process of collaborative goal setting should take place, in which treatment objectives are defined in a balanced approach to symptom con trol and normalization of activities, thereby enhancing overall wellbeing.
'First question' - establishing main problem When the physiotherapist starts off the subjective examination, the first thing to be determined is the main problem in the patient's own terms. It is import ant that patients be given every opportunity to express their reasons for seeking treatment, for example with the first question being: 'As far as you are concerned . . . [Pause . . ] (the pause helps the patient t o realize that the therapist is specifically interested in the patient's own opinion) . . . what do you feel . . . [Pause . . ] is your main problem at this stage?' The patient may start off by answering, 'The doctor said I've got tennis-elbow', or, 'Well, I've had this problem for 15 years'. In this case the physiotherapist may gently inter rupt with an 'immediate-response' question such as: .
.
Q A Q
'What made you go to tl1e doctor?' 'Well, because my shoulder hurts of course.' 'Ah, okay, it's your shoulder hurting' (and tl1en immediately making a note of this answer, which indicates to the patient that this is the information the physiotherapist is seeking).
After this answer the physiotherapist may determine the perceived level of disability. At this stage it is also essential to pay attention not only to what is said, but also to how it is said. The use of more emo tionally laden words ('it's all very terrible and annoy ing, I can't do anything anymore'), the non-verbal behaviour of expressing the main problem (e.g . looking away from the area of the symptoms while indicating this, a deep sigh before answering) or a seeming dis crepancy between the level of disability and the expected impairments or areas of symptoms may guide the physiotherapist to the development of hypotheses with regard to 'yellow flags' which may facilitate or hinder full recovery of function. In the determination of the localization of symp toms, at times it is important to ensure that certain areas are free of symptoms, in a sense if 'not even half of 1 %' exists. In this case 'immediate-response' questions need to be asked:
Q A Q
'Do you have any symptoms in your leg?' 'Not really.' 'Do you mean, nothing at all?'
The response to the examiner's first question with regard to the patient's main problem will guide the next question in one of two directions: the behaviour of the symptoms and the activities of daily living 2. the history of the problem. 1.
Communication and the therapeutic relationship
Behaviour of the symptoms Without experience in the choice of words or phrasing of questions, an enormous amount of time can be taken up in determining the behaviour of a patient's symptoms. Unfortw1ately, it needs time if the skill is to be learned, for nothing teaches as well as experience. The information required relative to the behaviour of a patient's symptoms is: •
•
•
• •
the relationship that the symptoms bear to rest, activities and positions the constancy, frequency and duration of the intermittent pain and remission, and any fluctuations of intensity ('irritability') the ability of the patient to control these symptoms and promote wellbeing (coping strategies) the level of activity in spite of the symptoms defining of first treatment objectives on activity and participation levels, as well as further coping strategies.
The following is one example that provides a guide as to the choice of words and phrases that will save time and help the therapist avoid making mistaken inter pretations and incorrect assumptions. The conversa tion that follows is with a man who has had 3 weeks of buttock pain. The text relates only to the behaviour of the buttock pain (adapted from Maitland 1986):
(ET, Examiner's thoughts; Q, question; A, answer) ET Earlier in the interview he said his buttock pain was 'constant'. 'Constant' can mean 'constant for 24 hours of the day' or 'constant when it is present' as compared with the momentary sharp pain. This is borne out by the fact that a surprising number of patients say their pain is constant, yet when you ask them, immediately prior to testing the first move ment, 'Do you feel any symptoms in your back at this moment?', they will answer 'No'. The 'constant ache' and 'no symptoms' are incompatible. To avoid misinterpreting his use of 'constant', it is essential that it be clarified. It may be possible to gain a more positive manner by tackling the ques tion from the opposite direction Q 'At this stage, are there any moments in which you do not feel your backache?' A 'No, it's there all the time.' ET The next question is to ask him is if he has any ache if he awakens during the night, because this is the most likely time for him to be symptom-free. Q 'How does it feel if you waken during the night?' A 'All right.' Q 'Do you mean it is not aching then?' A 'That's right.'
'Do you mean it is not aching at all?' 'That's right.' 'So you do have some stages when it is not aching?' 'Only at night. It aches all day.' That's now clear. His thinking processes at the moment relate to 'no symptoms in bed' and 'it aches all day'. I need to know the answers to two associated aspects of the daytime: 1. Does the ache vary during the day? (And if so, how much, why, and how long does it take to subside?) 2. Does he have any stiffness and/or pain on get ting out of bed first thing in the morning? To make use of his current train of thought, the following question should quickly be asked in response to his answer ' . . . it aches all day': Q 'Does the ache vary at all during the day?' A 'Yes.' ET Well, that doesn't help me much, but it does pro vide a point from which to work further. There are many ways I can tackle the next few questions. Basically, what I want to know is, does it increase as the day progresses or does it depend on particular activities or positions he may adopt? How can I get the answer most quickly? I'll try this first: Q 'What makes it worse?' A 'It just gets worse as the day goes on.' Q 'Do you mean there is nothing you know of which makes it worse - it just gets worse for no obvious reason?' ET Assessment and reassessment in particular are easier if there is something he can do to increase or to decrease his ache. I need to ask a more leading question: Q 'Is there anything you can do, here and now, which you know will hurt your buttock?' A 'Well, I know that while I have been sitting here it has ached more.' Q 'Do you mean, sitting normally makes you ache?' A 'If I sit and watch television it aches.' ET Good, this gives me more information with regard to physical examination and reassessment of treat ment. However I would like to know two things: 1. What can he do by himself to influence the pain? (This will provide me with information with regard to self-management strategies and phy sical examination.) 2. Are there any activities he performs which cause aching? (This information will also be helpful in later reassessment stages.) I first continue with his current line of thought sitting and watching TV cause ache. Q 'Once your back is aching during watching tele vision, is there anything you can do by yourself to influence the ache?' A 'I just get up and walk around for a while.'
Q A Q A ET
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L Q A Q A Q A
'Do you happen to perform any particular movements?' 'I am not aware of this.' 'Are you having any ache right now?' 'Yes.' 'What would you like to do right now to reduce it?' 'I would like to get up and walk a few steps.' (patient
gets up and PT observes) 'How is it now?' 'It's still there, but certainly better than just before.' 'Well, since this improves it a bit, I would suggest that getting up and moving around for a few moments is certainly a good thing to continue, whenever your back is aching more.' ET Well, 1 observed him getting up and supporting his back with his hands and he seemed to be having difficulty in straightening his back. This indicates a lumbar movement disorder rather than a hip dis order. In the latter case I would have expected him to have difficulty with walking rather than straight ening his back. He could also have moved his leg more to reduce the pain if the hip was a cause of his movement dysfunction. Now I would like to find out if there are some activities rather than positions which provoke his symptoms. 1 can combine this with one step of goal setting: Q 'So, if 1 understand you correctly, you would like sitting while watching television and getting up after sitting to improve, am I correct?' A 'Oh sure, that's right.' Q 'How do you feel when you first get out of bed in the morning?' A 'I have difficulty putting my socks on, 1 feel stiff and it aches in my buttock.' ET The greater value of this answer is the use of the spontaneous key word 'stiffness'. Stiffness in the morning may fit a recognizable clinical pattern of an inflammatory disorder, which can be deter mined by further questioning. Q 'How long does the stiffness last?' A 'Only a few minutes. I'm still aware of it when 1 lean over the wash-basin to wash my face, but by breakfast it has already gone.'
Q A Q
Some readers may consider the above answers are too good to be true. However, as the physiotherapist learns to ask key questions to elicit spontaneous answers, the responses become more informative and helpful in understanding both the person and his problem, hence the development of a therapeu,tic relationship and a dif ferentiated baseline for later reassessment procedures. The behaviour of the patient's symptom of stiffness may also be Significant when there is some pathology involved. For example, during the early part of the
examination the physiotherapist may develop the hypothesis that ankylosing spondylitis may be the back ground of the patient's movement disorder. The conver sation and thoughts may be something like this: ET 1 want to know if his back feels stiff on getting out of bed in the morning. If he has ankylosing spondyli tis, his back should be quite stiff and probably painful. Even if it is not very painful, does the stiff ness take longer than 2 hours to improve to his normal degree of limited mobility? To gain the maximum value from his answer 1 must avoid any suggestive questions. Q 'How does your back feel when you first get out of bed in the morning?' A 'Not so good.' Q 'In what way isn't it good?' A 'It's stiff.' ET This is a statement, and all statements need to be made factual if they are to be used for prognosis and assessment purposes. Q 'How stiff?' A 'Very stiff.' Q 'How long does it take for this stiffness to wear off?' A 'Oh, it's fairly good by about midday.' ET His job may involve shift work, so 1 must not assume immediately that his stiffness lasts for about 5 hours. Q 'What time do you get up in the morning?' A 'About 7 o'clock.' ET That means that he's stiff for at least 4 hours. That's too long for any ordinary mechanical movement disorder. History of the problem History taking is discussed in detail in Chapter 6. The discussion here relates to communication guidelines. Especially in those patients in whom the disorder is of a spontaneous onset, many probing questions are needed to determine the predisposing factors involved in the onset. The following text is but one example of the probing necessary in the history taking of this group of patients: ET If 1 start with open questions, which are vaguely directed, his spontaneous answers may help me considerably to understand those parts of his his tory that are important to him. Those parts which are important to me 1 can seek later, if they do not unfold spontaneously. Q 'How did it begin?' ET This may also provide me with information on when it began. A 'I don't know. It just started aching about 3 weeks ago and it isn't getting any better.' ET It is necessary to know what precipitated the pain and whether this was mechanical or not. If there
Communication and the therapeutic relationship
Q ET
A ET
Q A ET
Q A ET
Q A ET
was an incident or episode, it was either so trivial that he does not remember, or he doesn't associate it with his symptoms. Before sorting this out, it may save time for me to know if he has had any previous episodes. If he has, they may provide the key to rec ognizing the historical pattern of a particular move ment disorder, as well as the key to this kind of precipitating onset for the present symptoms. 'Have you ever had this, or anything like this before?' 1 have to be alert here because he may say 'No' on the basis that previous episodes have been called 'lum bago' and therefore he does not associate them with his present problem, which has been called 'arthritis'. 'No.' 1 can now direct my questions in several ways, but probably the most informative may be verifying this 'No' answer, as his present thoughts are directed now along 'past history'. 'Do you mean you've never had a day's backache in your life?' 'No, not really.' Ah . . . 'Not really' means to me that he has had something, so 1 must clarify this. 'When you say "Not really", it sounds as though you may have had something.' 'Well, my back gets a bit stiff if 1 do a lot of garden ing, but then everyone has that, don't they?' Now it's coming out. What I need to know is whether the degree of stiffness is related to the degree of gardening. 'How long does it take you to recover from a certain amount of gardening?' 'It might take 2 or 3 days to get back to normal after a whole weekend in the garden.' This is very useful information. It helps me to know what his back can tolerate, at least in previous episodes. 1 don't know yet if his back is about the same in this episode or if it's deteriorating, but to save time I'll go back to the 'here and now' and return to the gardening issue later - provided 1 do not forget about it! 1 will need to know the stability of the current disorder as it will guide me in the vigour of treatment and prognosis. The answer may come during other parts of the examination. W hat 1 need to know now is how this episode began. His initial vagueness indicates 1 am going to have to ask some searching questions to find the answers.
There are many ways the questions can be tackled, and the answer to each will take about the same length of time.
Q A
'You said that this episode started about 3 weeks ago. Did it come on suddenLy?' 'Yes, fairly quickly.'
ET Fairly quickly means 'suddenly' to him, but it's not precise enough for me, so I'll need to probe deeper. Q 'What were you first aware of?' A 'It just started aching.' Q 'During the morning or the afternoon?' A 'I don't remember: Q 'Do you remember if it came on in one day? In other words, did you have no ache one day and have an ache the next day?' After a delay, while he ponders the question, the answer comes: A
'Yes, 1 think so.' Q 'Do you happen to remember which day it was?' ET To pursue this line of thinking 1 will guide his memory, which may help him to remember something that might otherwise be lost. A 'It was a Thursday: Q 'Was it aching when you wakened that day or did it come later that day?' A 'I think 1 wakened with it, yes. Yes, I'm sure 1 did because 1 remember saying to my wife during breakfast that my back was aching.' Q 'And when you went to bed the night before, was your back aching then?' A 'No, then 1 did not feel anything.' ET That's part of the question solved, or at least as much as 1 need at the moment. Now to find out what provoked it. The first thing is to make him think about whether there was any trivial incident which occurred during the day before the backache started. If this proves negative, then I'll ask about 'predisposing factors'. Q 'Did you do anything at all on Wednesday that hurt your back even in a minor way, or made you aware of your back in any way?' A 'No, I've been trying to remember if 1 did anything, but 1 can't remember any time 1 could have hurt it: ET So now 1 have to resort to the 'predisposing factors' referred to above. While his mind is orientated towards physical activity, if I continue with ques tions associated with activities, he will probably be able to answer more quickly. And the answer may be more reliable. To ask him about the non physical activity 'predisposing factors' (fatigue, disease, etc.) will force him to change his train of thought and it may take more time. I will keep paralleling to his train of thought, as long as I do not lose the overview and don't forget about the other questions. Q 'Did you do any unusual work on that Wednesday or about that time?' A 'No.'
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'Have you been doing any heavier work than usual?' 'No.' 'Any work that was longer than usual?' 'No.' 'Anything changed at work, like new furniture?' 'No.' So there isn't any obvious physical activity which has provoked this ache. The next step is to investi gate the other 'predisposing factors' - there must be a reason for the onset of aching on the Thursday morning. Q 'At that time, were you unwell, or overtired or under any stress?' A 'Well, yes I was pretty tired. I'm overdue for holi days and we have had two men off work sick - and now you mention it, we have been working longer hours than usual to meet a deadline - I'd forgotten about that - and I was involved in a lot of lifting and carrying that day.' ET It often takes quite a long time (which is reason able) for a person to retrieve pieces of information, so rather than thinking, 'Why didn't you say that when I asked you earlier ', I'd be better to think, 'Well at least I didn't miss out on that piece of information' . Q 'And that is unusual for you, isn't it?' A 'Well, yes it is. I do have to do quite a bit of lifting, but the pressure was really on at that particular time.' ET Thank you very much, that's just what I was look ing for. Now that it makes sense, the history and the symptoms are compatible. Now I would like to know, as his train of thought is still '3 weeks ago', if he considered doing any self management interventions during the day he was lifting so much. Q 'During that Wednesday when you were lifting so much, did you think of doing any exercises in between to protect your back - or have you learned some things previously?' A 'Oh no, I was so busy, I did not think of anything other than getting the job done.' ET Okay, that's something I can understand. It pro vides me however with hypotheses regarding management - it could be a lumbar movement dysfunction, without prematurely excluding other sources. If it is lumbar, he may need to learn exten sion movements during the day to compensate for the bending activities. I'll keep that in mind and come back to this later. Q A Q A Q A ET
As already mentioned, when interviewing more gar rulous patients, trying to keep control of the interview is chalJenging. During history taking these patients
tend to go off at tangents and give a lot of detailed information. This may need to be skilfully interposed by gently increasing the volume of your voice and Simultaneously touching the patient gently. However, the important thing is that the examiner can retain con trol of the interview without insulting or upsetting the patient. Nevertheless, every effort should be made to make patients feel that they are not complaining, rather they should be told that they are informing 'What you don't tell me, I don't know.' For example the opening question and answer might be as follows: Q A
'When did it start?' 'Well, I was on my way to visit an old aunt of mine, and as I was getting onto . . . .'
This is often a difficult situation - is this the patient's train of thought, which may provide the therapist eventually with valuable spontaneous information, or is it better to interrupt? Some intervening questions to keep control of the interview may be as follows: Q l 'What happened?' Q2 'Did you fall?' Q3 'How long ago was this?'
Initial assessment: physical examination After a summary of the main findings of the subjective examination and agreed treatment objectives, it is essential that the patient is informed about the purpose of the test movements to allow the patient an active role in the procedures. This may be worded as follows:
'We have agreed that we would try to work on activities like bending over and standing. I've understood that it is important to you that you feel capable ofjogging again soon and inviting people to your home. Am I correct? (patient agrees). Now I would like to Look more specifically at your movements of your shoulder and neck, in order to see if they all meet the basic requirements to fulfiL such tasks. ' While performing the test procedures, the purpose of active test movements, as well as the parameters rele vant for reassessment procedures can be explained: Q A Q A Q A
'While standing here now, what do you feel in your neck and arm?' 'The whole lot.' 'Equally throughout?' 'No, the upper arm isn't so bad.' 'Your neck and forearm are more painful, aren't they?' 'Yes.'
Communication and the therapeutic relationship
Q 'Which is worse?' A 'They're about the same.' ET Right, that's dear. Now 1 would like to test neck flexion. The patient is asked to bend his head forward and then return to the upright position. 'Did your pain change?' 'Yes, the pain in my upper arm increased.' 'Did your forearm change?' 'No.' 'And nothing else changed either?' 'No.' 'Good. And now, has the upper arm pain subsided back to what it was before?' A 'Yes.' Q 'Did that happen immediately you started to come up, or did it take a while to subside?' A 'It hurt more while 1 was fully bent forwards.' ET That's ideal answering. 1 now have a complete picture of how the symptoms behave with for ward flexion of the neck. 1 have seen his range and quality of movement 1 wonder if he observed this as well. Q 'I want you to remember this movement - we will use it as a test later on to measure progress. Could you tell me something about how you perceived the way you moved - could you bend as much and as easily as YOLi are L1sed to?' A 'Can 1 do it again?' Q 'Yes.' A 'It feels much stiffer and 1 think I normally come further down.' Q 'I would like you to remember how the pain feels, but also to remember the way you feel able to move. Let's test the next movement now . . . Could you carefully bend your head backwards?'
Q A Q A Q A Q
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Patient does this and makes a grimace. 'Up you go. Where was it?' 'In my upper arm again.' 'How is it now?' 'Back to normal again.' 'How did you feel about the movement itself?' 'I did not feel free; 1 did not fully trust myself to go further back. 1 did not go as far as normal.' Q 'Which movement was more problematic: bending forwards or backwards?' A 'Backwards; it hurts more and 1 did not trust myself fully.' Q 'I would like you to remember this movement also. We will compare this one later on as well.' ET Now 1 would like to perform the other neck move ment, if the 'present pain' has not yet increased. Q A Q A Q A
This example demonstrates how much dose attention the pain responses to the movement deserve. The physiotherapist usually simultaneously observes the quality and range of movement. However, often it is necessary to guide the patient to this observation in order to teach him all the essential parameters of a test procedure. Furthermore, it is important for the patient to understand that the physiotherapist wants to use these movements in later reassessment procedures to observe if any beneficial changes have occurred. To many patients this is a strange procedure, as they often naturally would want to avoid the painful move ments. To omit precision in this area would be a grave mistake. Once the behaviour of the pain is established and the patient w1derstands the purpose of these test procedures, the treatment techniques can be suitably modified and the appropriate care given to treatment and reassessmen t. The intonation of the patient's speech can also express much to the physiotherapist. During the con sultation every possible advantage should be taken of all avenues of both verbal and non-verbal communica tion. The more patients one sees, the quicker and more accurate the assessment becomes. Q
'Now let me see you bending your head to the left side.'
And so the examination continues. The examples given should show how it is possible to determine very precise, accurate information about the responses to movement without great expenditure of time. Obviously it is not always as straightforward as the example given, but it is nearly always possible to achieve the precision. Some patients become quickly irritated in subse quent treatment sessions by being asked the same questions in the same detail. The physiotherapist who is tuned into the patient's non-verbal communication will quickly get this message. One way around this, without losing precision, is to vary the question: 'Upper arm again?' or, 'Only upper arm?', or, 'Same?' Palpation
During palpation sequences and examination of acces sory movements it is important to actively integrate the patient in the examination as well. Often the patient will be asked to comment only on any pain. However, if the patient is guided towards giving infor mation on his perception of the tissue quality and com paring the movements of various levels of the spine, he learns that many more subtle parameters may be relevant to reassessment procedures and hence to his wellbeing.
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L While performing, for example, accessory move ment of the cervicothoracic junction the following ver bal interactions may take place. Physiotherapist performs accessory movements of the C5-7 segments: Q A Q A Q
'How does it feel when 1 move on these vertebrae?' 'The lower one especially hurts.' (performs central PA movement on C7) 'So this one hurts you the most?' 'Yes.' 'If 1 move it a little bit less?' (moves less deep into the
direction of movement) A Q
A Q A
'Now it's less?' 'Yes.' 'And if 1 move so far (goes back to the point where she suspected the pain to start again), then it flares up again?' 'Yes.' 'And like this it is less again?' 'Yes.'
With this method of questioning the patient may learn several things: first, that the physiotherapist is truly interested not only in finding the painful segments of the spine, but also that the therapist does not want to hurt him unnecessarily. Second, the patient may develop trust in the physiotherapist. The physiotherapist examines now Tl-4, which are not painful, but have a very limited range of motion. Q A Q A Q
'If 1 move in this area, how is this?' 'Good.' 'Does anything hurt?' 'No.' 'Do you notice any difference in elasticity in this area compared with above?' (moves gently in Tl-4
area and then back to a more mobile, but pain-free area of the cervical spine) A Q
'Well, it's hard to say. It somehow seems much stiffer.' 'That's what 1 felt as well. 1 think that this area (C7) may have become so painful because these adjacent areas are stiff. 1 would like to gently move those painful areas in your neck with these fine move ments; however 1 would not like to go into the pain
(gently shows the movements on the neck of the patient).
This area (shows now at Tl-4) 1 would like to treat a bit later, as soon as 1 know how your neck reacts to these little movements. Could you sit up again, and we will quickly look at bending forwards and backwards - just to see if your neck has liked these little movements.'
Summarizing the first session: collaborative treatment planning and goal setting At the completion of the first session, after a subjective and a physical examination as well as a first probation ary treatment, including reassessment, it is essential to summarize the main points. This is relevant to train the clinical reasoning processes of the physiotherapist and to inform the patient about the viewpoints of the therapist, to clarify the goals of treatment once more and to define the interventions to achieve these objec tives. Furthermore, the parameters which indicate any beneficial treatment effects need to be defined collab oratively with the patient. The process of collaborative goal setting requires skill in communication as well as in negotiation. At times a patient may Simply expect to have 'less pain', although it seems in the prognosis that reduction in pain intensity and frequency may not be easily achieved. It may even be more challenging if the patient states that 'first the pain has to disappear and then 1 will think of work and activities'. Almost always it is relevant to define goals with control of pain and wellbeing, includ ing normalization of activities, as fear avoidance behav iour has been described as one of the major contributing factors to ongoing disability due to pain (Klenermann et al 1995, Vlaeyen & Linton 2000). However, not only the avoidance of activities but also the avoidance of social contacts and interesting stimuli such as going to a theatre are important contributing factors (Philips 1987). Furthermore, a lack of relaxation or lack of bodily awareness during activities of daily living may be rele vant contributing factors and may need to be included in the collaborative goal-setting process. The following interaction could take place: Q A Q A Q A Q A
Q
'What would be your main goal of the treatment with me?' 'To have less pain.' 'I understand that. If you had less pain, what would you do again that you are not doing now?' 'Well, 1 would like to work in the garden, 1 love roses.' 'Are there any other things that you would like to do again?' 'I would like to invite people to my house again.' 'What keeps you from doing this now?' 'Well, if 1 invite people to the house and cook for them, then 1 am afraid that the pain just comes at that time. And 1 cannot expect much help from my husband in that case.' 'So if 1 understand you correctly, if you could have a bit more control over your pain, for example with simple movements, you would invite people to
Communication and the therapeutic relationship
A Q
A Q
A Q
A Q
A
Q
A Q
your house again and work in the garden with your roses again?' 'Oh certainly!' 'When would you be satisfied with your pain? 1 mean, if your pain was like a wave on the ocean, now it is a very high wave, but does the water need to be totally flat?' 'Oh no, 1 certainly can accept some pain! It just should not get worse than it is right now.' 'Do you mean, that now your pain is acceptable, but it should not get worse?' 'Yes, that's right!' 'So if 1 understand you correctly, you would like to perform these activities again, but you do not trust yourself fully to do this?' 'Yes, 1 am afraid to do these things again.' 'What seems more important to you: having more trust in doing these things and controlling the pain a bit, or do you need to be fully pain free?' 'Oh no, 1 don't mind a bit of pain. If possible 1 would like to be able to cook again, to ride a bicycle and to work in the garden - just those things which make life so much more enjoyable.' 'How about trying to work together on activities like cooking and working in the garden and see if we find ways to control the pain, if this should flare up?' 'Well, yes . . . that would be wonderful of course.' '1 suggest that on the one hand 1 might perform some movements on your back to loosen it up a bit, as 1 did before. However, 1 also think we should find some simple exercises together which you could perform in your daily life, exactly when you may get more pain. Is that something you would be willing to try?'
Initially in this interaction it seems that the patient only seeks 'freedom from pain' in its intensity; however, after a few probing questions it becomes clear that the woman is more probably looking for a sense of control over her pain and developing trust in activities that she has avoided so far. The use of a metaphor for the pain (as in this example 'a wave on the ocean') frequently shows that in fact the patient is seeking control rather than simply reduction of pain and improvement in wellbeing. Often it is useful to take the time for this process of clarifying treatment goals as unrealistic expectations may be identified and the patient some times learns that there are other worthwhile goals to be achieved in therapy as well. Furthermore, it aids reassessment purposes as both the phYSiotherapist and patient learn to pay attention to activities which serve as parameters - for example, trust to move, and control over pain rather than sensory aspects of pain alone (e.g. pain intensity, pain localization and so on).
At times phYSiotherapists think they are involved in a collaborative goal-setting process; however, they may be more directive than they are aware (Chin A Paw et al 1993). In order to enhance compliance with the agreed goals, ideally it is better to guide people by asking questions rather than telling them what to do. The following example may highlight this principle: The patient is a 34-year-old mother of three little children who takes care of the household and garden, nurses her sick mother-in-law, and helps her husband in the bookkeeping of his construction business. She is complaining of shoulder and arm pain. The physio therapist is treating her successfully with passive movements in the glenohumeral joint. However, the pain is recurrent and the physiotherapist developed the hypothesis that lack of relaxation and lack of awareness of tension development in the body and during move ments may be very important contributing factors as to why the pain is recurring. The phYSiotherapist would like to start to work on relaxation strategies which could be easily integrated into the patient's daily life activities and subsequently would like to start to work on bodily awareness of relaxed movement during daily life functions (see also example on p. 65). Directive in teraction Q
A
'1 think you need more quiet moments during your day. Because you work so much, your shoulder can never recuperate. 1 suggest that you just take some time off every day for yourself.' 'Yes, 1 think you're right. I should do this.'
This directive way may develop an agreed goal of treat ment; however, the patient is not provided with any tools on how to achieve this goal. This may impede short-term compliance (Sluys & Hermans 1990). Furthermore, it has been shown that compliance with suggestions and exer cises may increase if goals are defined in a more collabo rative way (Bassett & Petrie 1997). Another approach may be: Collaborative goal setting b y asking questions
Q A Q
'1 think you must be quite stress resistant when 1 see all the things that you are doing in your daily life.' 'Oh, well, yes . . .' (reluctant) 'Yes?' (makes a short pause and looks the patient in
the eye) A Q A
'Oh well, sometimes it is a little bit too much.' 'What are you able to do, when you feel it is becom ing a bit too much?' 'Well, in 3 months' time my husband and 1 are going for a long weekend to Paris without the kids.'
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L Q
A
Q
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'Wow, that's wonderful! Hope you enjoy it! How ever, Paris is still a long time to go. What could you do in the meantime, when things get a bit too much? Have you discovered anything which you could do just during the day?' 'I don't know. 1 don't do anything special. 1 am not used to doing anything special for such things. Also at home when 1 was a kid we always worked a lot in our parents' business.' 'I think it would be useful if you could find some moments in the day in which to tank up a bit of energy again, before you continue with all your tasks. 1 think that your shoulder may benefit a lot from this.' (waits a moment and observes the patient) 'I have been thinking about that as well.' 'How would it be if we search for simple things which you could integrate into your daily life in which you can tank up a bit of energy? Maybe you already do very useful things in this regard, but if they're not done consciously, they may not be done frequently enough.' 'That's okay.' 'Could you describe a situation where you think it was all a bit too much for you in which your shoulder was hurting as well?'
Beginning of a follow up session : subjective reassessment Reassessment
In follow-up sessions spontaneous information about reactions to the last treatment is usually sought first, before a comparison to the parameter of the subjective examination is pursued explicitly. If the physiothera pist has suggested some self-management strategies to influence pain, it is also essential to address this some where in the subjective reassessment. It is important to remember at all times that statements of fact need to be converted into comparisons. The following communi cation could take place: 'Well now, how have you been?', or, 'How do you feel now compared with when you came in last time?' A 'Not too bad.' ET That tells me nothing, so . . . Q 'Any different?' A 'I don't know if this is usual, but I've been terribly tired.' ET Well, it seems that his symptoms have not been sig nificantly worse. However, 1 should not just assume that if they had been he would have said so straight away. The tiredness can be related and it can be a Q
favourable sign, so the response to his answer should be: Q 'Yes, it's quite common and it can be a good indica tor. How have your back and leg been?' A 'A bit worse.' ET Most responses need qualifying, but for 'worse' clarifying is mandatory: In what way?, Which part?, When?, Why? Spontaneous answers are still important, so I'll keep my questions as non directive as possible. 1.
In what way?
Q A Q A ET
what way is it worse?' 'My buttock has been more painful.' 'Sharper or more achy?' 'It's more difficult to get comfortable in bed.' That's not really answering my question, but it's telling me something about an activity, which I'm going to accept for the moment as being enough of an answer. 'In
2. Which part? ET Because he may have a nerve root problem 1 should determine if his calf pain has changed, and it would be better to do this before finding out the 'when' and 'why' of his increased buttock pain. Because 1 hope his calf hasn't worsened too, 1 am going to ask the question in a way that will influence him to say 'yes'. Q 'Do you mean your calf?' A 'No, that's about the same.' ET That's makes the answer to what 1 wanted to know very positive. 3. Q A Q A Q
A
When? 'When did you notice your buttock worsening?' 'Last night.' 'How about the night before?' 'No different from usual.' 'So there was no change from the time you left here after treatment until last night?' 'That's right.'
4. Why? ET It is essential to know if this increase was caused by treatment or other causes. 1 still don't know about his other activities. He may have done much more with his structures that he was not able to do before. Then it may even be a favourable response. At no time should 1 stop the subjective reassessment in this phase! Q 'Do you think it was what 1 did to you that made it worse?' A 'Not really, because the night before last was all right. And, actually, when 1 left here 1 felt better and 1 think 1 even had a better night than usual.'
Communication and the therapeutic relationship
ET That's a good answer - I know treatment did not make him worse, he even felt better. Let me check on that asterisk of sitting. Q 'So, you felt better after treatment and the night seemed better. How was sitting compared to before the treatment?' A 'Actually I think on the first day after treatment I could sit longer at work before it became uncom fortable as usual. However, yesterday I had to sit in an uncomfortable chair for 2� hours at a meeting during the evening - my buttock was quite sore during the last hour.' Q 'So after this sitting you felt the ache in your buttock more?' A 'Yes.' Q 'Did you feel anything in your calf then?' A 'No, only my buttock.' ET Well, the worsening seems related to his sitting, which was already a problem. I have already sug gested that he tries out a self-management exercise if his pain increases. I am aware that behaviour does not change over night, but I am curious to find out if he thought of trying out this exercise last night after the meeting, or if he stuck to his old habits. Q 'Were you able, last night, to try out that exercise I showed you last time?' A 'Exercise? No, I was so busy, I did not even think of it.' ET Okay, that's acceptable in the beginning - I have dif ficulty in changing my habits as well. But it shows me I have to repeat this exercise today during the session and I want to emphasize particularly the necessity of him trying it out, especially at those times when he has more symptoms. Now I want to know if he has recuperated to his initial state after this episode of sitting. Q 'After you went to bed and finally became comfort able, how was your night?' A 'I slept well, in fact I did not wake up at all last night.' Q 'Is that unusual?' A 'Well, it's at least 3 weeks since I could sleep a whole night. This is the first time since my buttock and leg started to hurt.' Q 'And how were you this morning compared with other mornings?' A 'I think about the same, back to what it was. A bit stiff for about 10 minutes and some difficulty put ting socks on.' Q 'Thank you. I'd like to summarize what I've heard, but please correct me if I'm wrong. Last night you had more difficulty getting comfortable in bed, but that this may be due to the longer period of sitting?' A 'Yes I think so.'
Q
A Q
A Q
'I can imagine that. It would be helpful the next time to try out that exercise of straightening your back to see if you can influence it.' 'Okay.' 'So last night you were more uncomfortable in your buttock, but your calf was the same. Immediately after treatment 2 days ago you felt better and you may have slept better. And last night YOLl could sleep the whole night for the first time for 3 weeks?' 'Yes that's correct. Overall I think I am a bit better.' 'Okay, now I would like to compare a few of the test movements of last time before we continue with treatment.'
If the physiotherapist had stopped this reassessment procedure relatively early in the conversation, impor tant information would have been lost and in fact the therapist may have stopped with the impression that the patient's situation had worsened. Especially in the beginning it takes questioning in much depth before the patient knows which details to observe and com pare. The phYSiotherapist needs to have a clear picture in mind of all the possible indicators of change, both in the subjective and in the physical examination. Too fre quently it can be observed in clinical situations that lack of in-depth questioning leads the physiotherapist to the interpretation that the situation has remained unchanged or worsened, but in fact the disorder has improved somewhat already. The questioning may also alert the patient to the necessity of trying out the self-management strategies the moment he starts to feel an increase in his symp toms, provided the exercises have been chosen with that objective. It is not unusual for patients to forget these self-management suggestions. However, this should not be interpreted as lack of discipline or moti vation; from a cognitive-behavioural perspective the education of self-management strategies deals with change of movement behaviour and habits, which usually do not change overnight.
Effects of self-management strategies
The way the physiotherapist reassesses the self management strategies may be crucial for the learning process of the patient and the initialization of change in movement behaviour. Random questions will often lead to random answers (Sluys et aI 1993): Q A Q A
'Have you been able to do your exercises?' 'Yes.' 'What did they do? Did they help?' 'No, not really.'
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L reassessed the lifting of your arm, it seems that your body liked the treatment as you could move the arm higher up and move it with more ease. The pain has not increased, but came on a little bit later in the range of movement. That's a good sign! Could I now check the other movements?
I n comparison with for example: Q
A Q
A Q
'Last time I recommended you try out two exercises - have you been able to think of these?' 'Yes, I've done them in the morning and in the evening.' 'Very good! You told me that you had symptoms in your shoulder and neck after writing at your com puter. Have you thought of doing the exercises then as well?' 'No, not at that particular moment. Maybe I should do them then as well.' 'Yes, that's a very good idea. It seems strange, but just at the time that something hurts it might be helpful to try this out. Maybe you can tell me next time what the effects were - are you going to work at your computer again?'
Reassessments of physical examination tests To determine the effect of a technique both the subjec tive and the physical parameters need to be assessed. The patient is asked if he feels any different from the treatment intervention. The following conversation shows how this can be done quickly, without sacrific ing the depth of information required. 'How do you feel now compared with when you were last in?' A 'About the same.' ET So subjectively he is about the same - now to check the movements. Q 'Do you remember a few of the test movements we did before?' A 'Yes, I lifted my arm, didn't I?' Q 'Yes - please could you compare that with before? How does your arm feel now?' ET I think he has gained about 20° in range before he made a grimace and the quality of the movement looked better. A 'It did not make my upper arm worse this time.' Q 'And now that your arm is down again, is it any worse as a result of lifting it?' A 'No.' Q 'Did you notice any difference in the way you moved?' A 'I think I could lift it a bit higher?' Q 'Yes, that's what I saw as well. You could move your arm higher before the pain started. How did it feel with regard to the quality of the movement? Did it feel any heavier or more difficult to move up?' A 'No, I think I could lift my arm a bit more easily.' Q 'Good. I would now like to summarize: we did these mobilization movements of your arm, which were not painful this time, and now that we have Q
It may be useful, especially if the patient feels that the symptoms have not changed, to ask if he feels that the quantity or quality of the movement has changed. There are at times situations where the patient starts to move more freely with more range, but the pain is still the same, so the patient experiences everything as being the same, although parts of his movements are already changing. By asking patients about these other aspects of the movement, they may learn about this and concentrate more on the aspects of the test move ment as well. Summarizing the information gained out of the reassessment frequently reinforces this learning process.
During a treatment intervention It is essential while performing a treatment technique such as passive mobilization to maintain communica tion. On the one hand, the physiotherapist wants to assess any changes in resistance to movement or motor responses - on the other hand, the therapist needs to know of any changes in symptom reaction to the movement. There may be no pain, or no pain to start with, but soreness may occur as the technique is con tinued; alternatively, while performing the technique there may be soreness or reproduction of the patient's symptoms, which behave in various ways: The symptoms decrease and disappear (they may increase during the first 10--20 seconds and then decrease). 2. The symptoms may come and go in rhythm with the rhythm of the technique. 3. An ache may build up which is not in rhythm with the technique. 1.
The communication issues associated with determin ing the behaviour of symptoms during the perform ance of the technique are related to trying to help the patient understand what the differences might be, so that he can give a useful answer: ET Now that I have started performing the technique I must know straight away what is happening to the patient's symptoms. Q 'Do you feel any discomfort at all while I am doing this?' A 'No, I can't feel any discomfort at all other than the stretching.'
Communication and the therapeutic relationship
ET This state of affairs may change fairly quickly, so in about 10 seconds I will ask again. Q 'Still nothing?' A 'No, I can feel a little in my left buttock now.' Q 'And that wasn't there when I started?' A 'Yes it was there, it's always there.' Q 'Has it changed since I started?' A 'Yes, it's slightly worse.' ET What I need to know now is whether this is a grad ual build-up into an ache, or whether it is going to 'come and go' in rhythm with the technique. To make it easier for him, the question is better asked in such a way that he can choose between two statements. Q 'Does it come and go in rhythm with the move ment, or is it a steady ache?' A 'It's just a slight ache.' ET What I need to determine as quickly as possible is whether it is going to increase with further use of the technique, whether it will remain the same, or whether it will decrease and go.
Directive communication Q
'You should not sit like this. That will certainly provoke pain. I think it is better that you take care in your daily life not to sit in so much tension. I will show you the exercise once again and I sug gest you do this exercise three times a day and, of course, when it hurts as well.' (shows the patient
once again how to relax the shoulders more towards a neutral position) A Q
'Okay.' 'I'll see you then next time.'
Next session: Q A Q
A Q A
'How have you been since last time?' 'I still have pain.' 'Have you been able to do that exercise I showed you last time?' 'Yes.' 'Could you show me once again?' 'Em . . . , I don't know if I have done it right, could you show me again?'
After a further 10 seconds, the question is asked:
In
Q 'Is it just the same or increasing?' ET The question in asked in this way because it is hoped that the symptoms will be decreasing and therefore it is better to influence the answer towards what is not wanted rather than to get a false answer suggested by me. A 'It's about the same.'
Mirroring, guiding by asking questions, including reassessments
Ten seconds later: Q A
'How is it now?' 'It's less, I think.'
In another 10 seconds: Q 'And now?' A 'It's gone.' ET That's an ideal response. I also had the impression that I could move further into the range. I will record this response later.
such cases the physiotherapist may be disappointed that the patient seems to have forgotten the exercise. However, this may be due to the timing within the ses sion (in the last few minutes of the session) and the quality of communication.
Q A Q A Q
A
not change anything immediately) Q A Q
Treatment and education of bodily awareness Communication is important not only during the application of passive movement techniques, but also during education of bodily awareness. The 34-year-old patient described in the communication examples of collaborative goal setting had a tendency to pull her shoulders in protraction and elevation. Although it may seem time consuming, a different communication technique may have immediate effects on understanding and compliance.
'How are you now?' 'It hurts at my shoulder.' 'Do you notice anything different about your posture?' 'No.' 'I see that you have pulled your shoulder forwards and up.' (mirrors the positions) (observes herself now) 'Oh yes, that's right.' (but does
A Q A Q A Q A Q
'Would you be able to change something?'
(pulls shoulders very far down and in retraction) 'Like this?' 'Maybe a little bit less. (guides the movement) How does it feel now?' 'That feels fine.' 'Anything that hurts you right now?' 'No.' 'You mean nothing of the shoulder pain that you had right before?' 'No.' 'Could you please pull your shoulder up and for wards, as you did before?' (performs the movement) 'How does it feel right now?'
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A
'That hurts at my shoulder.' (but does not change
automatically) Q
'How about trying to relax your shoulder again.'
(guides the movement, tactile) A Q A Q A
'Now it's gone.' 'Could you please do that again?' (pulls the shoulder up again) 'That hurts again.' 'And if you change the position again?'
A Q A Q A Q
A
'I suggest you monitor yourself a bit during the daytime, this afternoon and tomorrow. Maybe you'll notice that you pull up your shoulder quite frequently. We all often move automatically, with out thinking - I notice that with myself as well. Shall I explain what happens to your body when you perform such movements?' 'Yes please.'
(explains the principle of the bent finger; McKenzie 1 981) 'Aha!' 'Could you imagine that similar things happen in your shoulder?' 'Oh well, yes.' 'I have explained a lot to you - however I'm not sure if I've done a good job. Would you mind explaining to me in your own words what you've understood?' 'If I am sitting in such a tensed position the blood circulation is in trouble. If I move differently it is better. '
This has been a reassessment on a cognitive level. If the patient is invited to explain in her own words, the physiotherapist immediately understands if the expla nation 'touched ground' and in the patient herself deeper understanding may be enhanced. Q
Q A
Q A
(performs the movements without the aid of the physio therapist) 'Now it is much better again.'
In this case the reassessment is not only the evaluation of the symptom responses, but also the patient auto matically changing her movement behaviour as hap pened in the third repetition. To follow the sequence with cognitive reinforcement and explanation will often be useful. Q
Next session:
'Then I would like to suggest that you focus on your shoulder a few times during the day, to check if you are pulling it up, particularly when you feel it is hurting again. Maybe you could try this simple exercise then. If this helps you, then we come closer to understanding your pwblem. However, if it does not help, then we have to look for alternatives. So please try it and feel free to tell me if you think it is successful or not.'
'How have you been since last time?' 'I have noticed that I have this silly habit of pulling my shoulder up. I've paid more attention to this and I feel it's getting better already.' 'How did you notice that?' 'It does not hurt so much now and I am able to complete all the tasks that I have to do during the day.'
Retrospective assessments (after three to five treatments) Frequently it is necessary to assess the progress in the patient's symptoms and signs compared Witll those at the first visit. The physiotherapist may also have employed various interventions, the effects of which need to be determined. Furthermore, it needs to be clarified collaboratively with the patient if the agreed treatment objectives are still relevant or if new goals need to be defined. The latter becomes especially important if the patient is supported towards resum ing activities at work or in hobbies. A valuable question is: 'How do you feel compared with before we began?' The answer enables ilie phys iotherapist to see the progress in its proper perspec tive. It sometimes happens that a patient reports at each successive treatment to be feeling a bit better, yet at the fourth treatment session may say, 'Well . . . I'm not any worse.' It is for reasons such as this that retrospective assessment must be made a routine part of the thera peutic process. Sometimes the patient may be asked to define the percentage of progress: Q
'What do you think the percentage of improvement has been compared with when we began?'
For some patients it is difficult to think in these terms, in which case they may be asked : Q
A
'Do think you are less than halfway to being com pletely better?' 'Oh no, I'm more than half better, thank you.'
The communication may then continue, for example, as follows: Q
A
'That sounds good, tell me in what way are you better?' 'The aching doesn't bother me during ilie day now and when I get out of bed in ilie morning I don't feel stiff any more. Also I can put my socks on wiiliout any difficulty.'
Communication and the therapeutic relationship
'That's good. Any symptoms left? How is your day?' 'I still feel it a bit after I've been sitting for a long time.' 'Sitting for how long?' '2-3 hours.' 'Anything you can do about it then, once it comes on?' 'Well, as you suggested, I move my back or I put my arm or a pillow in my back while I'm sitting or I stand up and do this straightening exercise.' 'Do you feel this allows you to sit for longer?' 'Yes, then I can get on with my work again.' 'How's that in comparison with the first treatment?' 'Oh, then I could sit for only 10 minutes, so I think that's quite a step forward, isn't it?'
A : ' I would like t o play golf and tennis again.' Q 'Are there any particular movements that you think may be difficult?' A '1 think at golf only the bending down to pick up a ball. At tennis I'm not so sure, the quick changes and the deep reaching at forehand - I don't know.' Q 'Let's take these movements into the reassessment procedures and I think we should start to train them. Could you bring in a golf club with you the next time?'
After the assessment of the symptoms, activity levels and the employment of self-management strategies, it is essential to assess the subjective effects of the treat ment. The physiotherapist may ask, for example:
In this phase it is the objective not only to evaluate the overall therapeutic process so far, but also to anticipate possible future difficulties in order to enhance the patient's long-term compliance with the suggestions, instructions and self-management strategies (Sluys 2000). Similar questions may be posed as described in retrospective assessment. The anticipation of future difficulties may take place as follows:
Q
A Q A Q
A
Q A Q
A
Q
'I have done various things in the first few sessions. Is there anything that you think has been especially helpful - is there anything that you feel I certainly should not do to again?'
Furthermore, it is often useful to reflect on the learning process: Q
A
Q
A
'From all the things we have discussed and done, which has been particularly useful for you? In other words, what have you learned from the therapy so far?' 'I understand now that my being in the same posi tion for a long time may provoke pain. I've been working so hard over the last 2 years that I did not have time for my usual sports and when I was working I was concentrating so hard that I forgot about the stress on my body.' 'Is there anything that is particularly useful to you to do now for this?' 'Well, I feel it is really useful to think of the move ments of my back once I'm at work and I am already thinking of returning to my sports again.'
After having established this, a prospective assess ment in which treatment objectives are redefined may be useful: Q
A Q
'On which activities should we work together in the next period of treatment?' 'Well, I don't know, you're the therapist.' 'You told me you wanted to go back to your sports which sports?'
Similar questions need to be asked with regard to working situations, before reassessing the physical examination tests.
Final analytical assessment
Q
A Q
A Q A Q A
Q
A
Q
'We have now looked back at the therapeutic process. I'm glad that I've been able to help you so far. In the future, where would you anticipate diffi culties may arise again?' 'I don't know. 1 think if 1 stick to the exercises you taught me I should be in good shape, 1 guess.' 'I think so. However, we are all only human, so it may be that you forget some of the exercises over time. Which exercise would you do first, just in case your back started to hurt again?' 'I guess I would start with the straightening exercises.' 'When would you do them particularly?' '1 believe I would think of them after sitting or bending over.' 'Anything else?' 'Well, if 1 bend over for a longer period, it is also helpful to tuck my belly in, so 1 think 1 should not forget about that one too.' 'Are there any working activities which you think could cause you difficulties?' 'Well, 1 help out with a gardener at times - in spring we often put up fences and then 1 may lift a lot and may use a heavy sledgehammer.' 'Oh, that may be important. Can you show me the way you would do this?'
67
68
M A I T LA N D ' S P E R I P H E R A L M A N I P U LAT I O N
L CONCLUSION Although this discussion about communication and its problems may seem lengthy, it merely touches the surface of the subject. Communication and the establishment of a therapeutic relationship nowadays
have been declared an integral part of physiotherapy (WPCT 1999, Mead 2000). However, communication is both an art and a skill which needs careful attention and ongoing training in order to enhance the assess ment and treatment process between the patient and the physiotherapist.
References Alsop, A. & Ryan, S. 1996. Making the Most of Fieldwork Education - A Practical Approach. London: Chapman and Hall Bassett, S. E & Petrie, K J. 1997. The effect of treatment goals on patient compliance with physiotherapy exercise programmes. Physiotherapy, 85, 130-137 Brioschi, R 1998. Kurs: die therapeutische Beziehung. Lei tung: R Brioschi & E. Hengeveld. Fortbildungszentrum Zurzach, Mai 1998. Burnard, P. 1994. Counselling Skills for Health Professionals. London: Chapman and Hall Charmann, R A. 1989. Pain theory and physiotherapy. Physiotherapy, 75, 247-254 Chin A Paw, J. M. M., Meyer, S., De Jong, w. et al. 1993. Therapietrouw van cystic fibrosis patienten. Nederlands Tijdschrift voor Fysiotherapie, 105, 96-104 de Haan, E. A., van Dijk, J. P., Hollenbeek Brouwer, J. et al. 1995. Meningen van clienten over de kwaliteit van fysiotherapie: verwachting en werkelijkheid. Nederlands Tijdschrift voor Fysiotherapie, 105, 18-22 French, S. 1988. History taking in the physiotherapy assessment. Physiotherapy, 74, 1 58-160 French, S., Neville, S. & Laing, J. 1994. Teaching and Learning - A Guide for Therapists. Oxford: Butterworth Heinemann Gartland, G. J. 1984a. Communication skills instruction in Canadian physiotherapy schools: a report. Physiotherapy Canada, 36, 29-31
Gartland, G. J. 1984b. Teaching the therapeutic relationship. Physiotherapy Canada, 36, 24-28
Grant, R 1. E., ed. 1994. Manual therapy: science, art and placebo. In Physical Therapy of the Cervical and Thoracic Spine. New York: Churchill Livingstone Hiirkiipiiii, K, Jarvikoski, A., Mellin, G. et al. 1989. Health locus of control beliefs in low back pain patients. Scandinavian Journal of Behavioural Therapy, 18, 107-118 Hayes, K. w., Huber, G., Rogers, S. & Sanders, B. 1999. Behaviors that cause clinical instructors to question the clinical competence of physical therapist students. Physical Therapy, 79, 653-667, discussion 668-671 Hengeveld, E. 2000. Psychosocial Issues in Physiotherapy: Manual Therapists' Perspectives and Observations. MSc Thesis. London: Department of Health Sciences, University of East London Hengeveld, E. 2003. Compliance·und Verhaltensiinderung in Manueller Therapie. Manuelle Therapie, 7, 1 22-132 Horton, J. & Bayne, R, eds. 1998. Counselling and Communication in Health Care. Counselling and
Communication Skills for Medical and Health Care Practitioners. Leicester: BPS Books.
Jensen, G., Shepard, K E & Hack, 1. M. 1990. The novice versus the experienced clinician: insights into the work of the physical therapist. Physical Therapy, 70, 314-323 Jensen, G. M., Shepard, K E, Gwyer, J. & Hack, 1. M. 1992. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Physical Therapy, 72, 711-722 Kendall, N. A. S., Linton, S. J., Main, C. J. et al. 1997. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss.
Wellington, New Zealand: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee Keogh, E. & Cochrane, M. 2002. Anxiety sensitivity, cognitive biases, and the experience of pain. Journal of Pain, 3, 320-329 Kerssens, J. J., Jacobs, c., Sixma, H. et al. 1995. Wat patienten belangrijk vinden als het gaat om de kwaliteit van fysiotherapeutische zorg. Nederlands Tijdschrift voor Fysiotherapie, 105, 168-173 Klaber Moffet, J. & Richardson, P. H. 1997. The influence of the physiotherapist-patient relationship on pain and disability. Physiotherapy Theory and Practice, 13, 89-96 K1einmann, A. 1988. The Illness Narratives - Suffering, Healing and the Human Condition. New York: Basic Books K1enermann, 1., Slade, P. D., Stanley, 1. M. et al. 1995. The prediction of chronicity in patients with an acute attack of low back pain. Spine, 20, 478-484 KNGE 1998. Beroepsprofiel Fysiotherapeut. Amersfoort l Houten: Koninklijk Nederlands Genootschap voor Fysiotherapie/Bohn Stafleu van Loghum Lawler, H. 1988. The physiotherapist as a courisellor. In Physiotherapy in the Community. Cambridge: Woodhead Faulkner Main, C. J. 2004. Communicating about pain to patients. Schmerzen, alles klar? Zurzach, Switzerland Main, C. J. & Spanswick, C. C. 2000. Pain Management An Interdisciplinary Approach. Edinburgh: Churchill Livingstone Maitland, G. D. 1986. Vertebral Manipulation, 5th edn. Oxford: Butterworth-Heinemann Maitland, G. D. 1991. Peripheral Manipulation, 3rd edn. Oxford: Butterworth-Heinemann. Mattingly, C. & Gillette, N. 199 1 . Anthropology, occupational therapy and action research. American Journal of Occupational Therapy, 45, 972-978
Communication and the therapeutic relationship
May, S. 2001. Patient satisfaction with management of back pain. Part 1: What is satisfaction? Review of satisfaction with medical management; Part 2: An explorative, qualitative study into patients' satisfaction with physiotherapy. Physiotherapy, 87, 4-20 McKenzie, R. 1981. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications Mead, J. 2000. Patient partnership. Physiotherapy, 86, 282-284
Merry, T. & Lusty, B. 1993. What is Patient-Centred Therapy? A Personal and Practical Guide. London: Gale Publications Philips, H. C. 1987. Avoidance behaviour and its role in sustaining chronic pain. Behaviour Research and Therapy, 25, 273-279
Pratt, J. W. 1989. Towards a philosophy of physiotherapy. Physiotherapy, 75, 114-120
Riolo, L. 1993. Commentary to Sluys, Kok & van der Zee (1993). Physical Therapy, 73, 784-786
Roberts, 1., Chapman, J. & Sheldon, F. 2002. Perceptions of control in people with acute low back pain. Physiotherapy, 88, 539-548
Rogers, C. R. 1980. A Way of Being. Boston: Houghton Mifflin Rotter, J. 1966. Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, General and Applied, 80, 1-5
Schachter, C. 1., Stalker, C. A. & Teram, E. 1999. Towards sensitive practice: issues for physical therapists working with survivors of childhood sexual abuse. Physical Therapy, 79, 248-261
Schon, D. A. 1983. The Reflective Practitioner. How Professionals Think in Action. Aldershot: Arena Schulz von Thun, F. 1981. Miteinander Reden - Stonmgen und Kliirungen. Allgemeine Psychologie der Kommunikation.
Reinbek bei Hamburg: Rowohlt Taschenbuch Verlag Schwartzberg, S. 1. 1992. Self-disclosure and Empathy in Occupational Therapy. Invited Paper at Occupational Therapy Conference, Trinity College, Dublin Sim, J. 1996. Focus groups in physiotherapy evaluation and research. Physiotherapy, 82, 189-198
Sluys, E. 2000. Therapietrouw door Voorlichting - Handleiding voor Patientenvoorlichting in de Fysiotherapie. Amsterdam: Uitgeverij SWP Sluys, E. & Hermans, J. 1990. Problemen die patienten ervaren bij het doen van huiswerkoeferungen en bij het opvolgen van adviezen. Nederlands Tijdschrift voor Fysiotherapie, 100, 1 75-179
Sluys, E. M., Kok, G. J. & van der Zee, J. 1993. Correlates of exercise compliance in physical therapy. Physical Therapy, 73, 771-786
Stenmar, 1. & Nordholm, 1. A. 1997. Swedish physical therapists' beliefs on what makes therapy work. Physical Therapy, 77, 414-421
Stone, S. 199 1 . Qualitative research methods for physiotherapists. Physiotherapy, 77, 449-452 The Age. 1982. 21 August Thomson, D., Hassenkamp, A. M. & Mainsbridge, C. 1997. The measurement of empathy in a clinical and non clinical setting. Does empathy increase with clinical experience? Physiotherapy, 83, 1 73-180 Trede, F. V. 2000. Physiotherapists' approaches to low back pain education. Physiotherapy, 86, 427-433 Van der Linden, M. 1998. Therapeutische relatie: een specifieke of een non-specifieke factor. NBMF-Nieuws, 1, 12-15
VJaeyen, J. & Linton, S. 2000. Fear avoidance and its consequences in chronic pain states: a state of the art. Pain, 85, 317-332
Wall, P. D. 1994. The placebo and the placebo response. In Textbook of Pain, ed. P. D. Wall & R. Melzack. Edinburgh: Churchill Livingstone Watzlawick, P., Beavin, J. & Jackson, D. J. 1969. Menschliche Kommunikation. Bern: Huber Verlag. WCPT. 1999. Description of Physical Therapy. London: World Confederation of Physical Therapy WHO. 2001. ICF - International Classification of Functioning, Disability and Health. Geneva: World Health Organization Wiegant, E. 1993. Tussen intimiteit en sexueel rnisbruik. FysioPraxis, 16, 24-27
69
71
Chapter 4
Contemporary perspectives in physiotherapy practice
THIS CHAPTER INCLUDES: • • •
•
Key words for this chapter Glossary of terms for this chapter Some contemporary perspectives in physiotherapy and the influence on and by the Maitland Concept of manipulative physiotherapy Paradigms in physiotherapy
KEY WORDS Biopsychosocial paradigms, movement
GLOSSARY OF TERMS Body of knowledge - theory which underpins clinical practice. Research in principle should contribute to the body of knowledge of a profession by generating and testing theories. Currently the body of knowledge of the physiotherapy profession is embedded in a biopsychosocial movement paradigm. The 'movement continuum theory' (Cott et al 1995) may serve as the model of practice and research in which all concepts of physiotherapy may find a place. Clinical reasoning - 'The thinking and decision-making processes associated with clinical practice' (Higgs Et Jones 2000). In a more
•
•
Movement as the central core in physiotherapy, including physiotherapy diagnosis The International Classification of
• •
•
Functioning, Disabilities and Health and its role in physiotherapy diagnosis
•
The pain revolution The role of movement in the treatment of pain Research and the body of knowledge of physiotherapy Clinical reasoning, research and assessment.
paradigms, physiotherapy diagnosis, quantitative and qualitative research,
clinical reasoning.
phenomenological perspective clinical reasoning concerns not only the medical diagnosis but also the patient and the personal illness experience. It is more than applied science; it is more likely 'applied phenomenology'. During a therapeutic session a clinical judgement is made about causes, ways to treat and how to integrate the patient actively in the rehabilitation process. The therapist may not always be explicitly aware of all the decisions made during this process (Mattingly Et Fleming 1994). Physiotherapists engage in complex forms of clinical reasoning in which they follow different paradigms. Individual illness experience - the personal experiencing of bodily
processes and the impact of social and cultural influences on this experience (Kleinmann 1988). Paradigm - model of practice or research. Kuhn (1962) had a formative influence on the awareness of paradigms in medical practice and research. By looking at the history of scientific developments he recognized that in each scientific community a set of presuppositions existed which guided the research of that group. Within a paradigm, assumptions, problems, research strategies, criteria and techniques are shared and often taken for granted by the community. Kuhn argued that a set of overt disagreements between natural scientists and social scientists existed about the nature
72
MAITLAND'S PERIPHERAL MANIPULATION
L
of legitimate scientific problems and methods, in which each group may be unaware of the paradigms of the other group. Paradigms function as maps or guides which dictate the kinds of issues to address, theories which are acceptable and procedures to solve the defined problem (Kuhn 1962). A shift in paradigm will take place if certain phenomena do not fit, are contradictory or cannot be explained by the existing dominant paradigm. Phenomenology - developed as a counter-movement to positivism in
the 18th century, this challenges the appropriateness of a positivist approach to research by stating that humans cannot be reduced to measurable units that would exist independently of their historical, cultural and social context. The topics of research within the philosophy of phenomenology are the values and the matters which seem to be significant to individuals within a certain context (Parry 1991). Salutogenic perspective Antonowsky (1987) suggests not only focusing on pathogenic
INTRODUCTION
•
stressors in research but also on those factors which promote health. A sense of coherence is described as an important contributing factor to a sense of health. He suggests that health is not a static state, but that it needs to be defined on a 'dis-ease' to ' ease' continuum. Physiotherapists may guide patients from an individual health experience and illness behaviour towards a sense of wellbeing and health-promoting behaviour with regard to movement functions.
An increasing number of physiotherapists have become
engaged
in
profession-specific
research
The physiotherapy profession saw widespread devel
underpinning physiotherapy practice and contribut
opment over the last four to five decades of the 20th cen
ing to the body of knowledge of the profession.
tury. Physiotherapists seemed to identify with a variety of the concepts and treatment methods that evolved
•
rather than with a common denominator. However,
ing physiotherapy practice and research. This devel
over the years there was a recognition of the need to: •
opment has brought forward physiotherapists who concern themselves with the philosophy of clinical
define and describe the specific role of physio
practice and research.
therapists in the medical landscape and in society (Hislop 1975, Parry 1991, Rothstein 1994, Belanger
•
1998) •
researchers, health-care policy makers, administra
identify common denominators in all the concepts
tors, etc. on the scope of current physiotherapy practice.
APTA 1988, KNGF 1992, Parry 1997, WCPT 1999) describe the specific body of knowledge to which research efforts should contribute (Hislop 1975, Parry 1991, Cott et al 1995, NPI 1997). Due to many professionalization efforts, physiotherapy has been going through an emancipation process in which it has become an increasingly autonomous pro fession. The development has encompassed various aspects: •
In many countries physiotherapists have moved away from an auxiliary status to direct-contact practitioners and increasingly assume their roles as equal partners in interdisciplinary teams.
•
The publication of descriptions of the physio therapy profession to inform clinicians, educators,
that constitute physiotherapy practice (Hislop 1975,
•
Within this context, discussions have been initiated regarding which specific paradigms should be guid
Based on a review of former editions of Maitland's pub lications, it may be concluded that these developments were not unobserved by Maitland, since he started prac tising in the 1950s. On the other hand Maitland himself, among others, by his numerous publications and lectur ing, contributed to the development of the identity of the physiotherapy profession. In particular, the follow ing aspects of the 'Concept' may have been of influ ence on certain achievements in the above-mentioned professionalization process. •
'Brick wall' analogy
(Chapter 1) - in the brick wall
analogy it is suggested that physiotherapists fol low a different decision-making process from that of other professionals (e.g. medical doctors) with
Higher degree courses have become available in
regard to the shaping of treatment. In this pro
many countries worldwide.
cess physiotherapists employ various paradigms
Contemporary perspectives in physiotherapy practice
•
simultaneously, as delineated in the clinical and
the results of research should contribute and within
theoretical sides of the brick wall analogy.
which paradigms clinical practice and research should
Assessment
-
one
of
the
first
publications
by
Maitland addressed the relevance of examination and assessment before embarking on a treatment process. It was emphasized that the specific clinical presentation of symptoms and signs (of movement dysfunctions) should guide the clinician in making decisions regarding treatment rather than the bio medical diagnosis itself. Although theories may change over the years, the primacy of clinical evi dence - in which the physiotherapist should prove if the chosen path of treatment is beneficial to the patient - will always remain a core element of clin ical practice (Chapter 5). •
be conducted (Shepard 1987, Jensen 1989, Parry 1991, Stone1991, Hullegie1995, NPl1997, Parry1997). It appears that the dualistic biomedical paradigm, dominant in both medical and physiotherapy practice since the 19th century, is increasingly being questioned as the basis for clinical practice and research. Within physiotherapy practice and research it is argued that
physiotherapists traditionally seem
to
adhere to a biomedical paradigm. This is explained from a historical viewpoint in which the founders of the physiotherapy profession in the19th and 20th centuries accepted medical hegemony and adopted the current biomedical perspectives on their work in exchange for professional recognition and permission to practise
The art of manipulative physiotherapy - in concert with
(Parry 1991, Barclay 1994, Welti1997). However, various
other founders of the International Federation of
physiotherapists believe that the dominant biomed
who
ical model should be replaced by a profession-specific
worked tirelessly for the integration of the 'art of
Orthopaedic
Manual
Therapists
biopsychosocial model of practice (Pratt 1989, Moon
manipulative
1990, Barclay 1994, Parry 1995, Carpenter 1997, Koke
physiotherapy'
(IFOMT),
(including
passive
movement and treatment progression) into the core
1997, Welti 1997, Wright 1999a).
skills of physiotherapists, passive movement may be considered as a 'kick-start' to active movement and may be an essential intervention in the overall rehabilitation process of patients. • •
Commitment to the patient
-
The biomedical model has been challenged by Engel
see Chapters 1 and
Communication and the therapeutic relationship
3. - the
Concept emphasizes the importance of communica tion and the development of a therapeutic relation ship at an early stage in the physiotherapist's personal professional development (Chapter
Biopsychosocial model
3).
(1977), who argues that the model places too much emphasis on explaining illness and disease by devi ations in biological processes. The biomedical model creates, according to Engel, a dichotomy with organic elements of a disease on the one hand and, on the other, the psychosocial elements of human malfunc tion, which are often too easily associated with causal
With the brick wall analogy Maitland moved away from
principles such as psychopathology or psychosocial
the biomedical diagnosis as the primary basis for deci
problems.
sions regarding the selection and application of physio
From a biopsychosocial perspective it is suggested
therapy treatments. Furthermore, he accentuated the
that various factors may contribute to the develop
necessity of independent decision-making processes by
ment and maintenance of disease, pain and disability:
physiotherapists in order to provide the best manipula tive physiotherapy care possible. However, Maitland
•
biological processes
emphasized that manipulative physiotherapy should
•
emotional aspects
always occur under the umbrella of recognized medical
•
cognitive aspects
and health-care practice (Maitland 1995).
•
social factors
•
cultural factors
•
behavioural factors.
PARADIGMS AN D THEORETICAL MODELS From biomedical to biopsychosocial frameworks Currently the medical and physiotherapy communities
Engel's ideas seem to receive increasing attention and acceptance in various fields of medical practice as dif ferent authors suggest following a biopsychosocial para digm, for example in the assessment and treatment of
have started to question the paradigms underlying
whiplash-associated disorders (Ferrari & Russel 1999),
clinical practice and research. In the field of physiother
in the management of low back pain (Waddell1987), in
apy, with the increasing wealth of profession-specific
the treatment of headaches (Holroyd et al1999) as well
research, it has been asked to which body of knowledge
as in the treatment of rheumatoid arthritis (Teasel &
73
74
MAITLAND'S PERIPHERAL MANIPULATION
Merskey 1997) or in the support of cancer patients (Turk et al 1998).
which promote a move forward towards an experi
Within the biopsychosocial model, the phenomeno logical construct of the 'individual illness experience' plays a central role. This relates to the personal experi encing of bodily processes and the impact of social and cultural influences on this experience (Kleinmann 1988). The following aspects are emphasized: •
The illness experience is always culturally shaped appropriate illness behaviour, on the personal biog raphy of the person, and on psychological processes, meanings and relationships, so that the social world is always linked with the inner experience of feel ing ill. In this experience powers may exist that can either amplify or reduce suffering and disability, includ ing the
•
behaviours of others as relatives or clinicians.
Every professional is trained to
transLate the
illness
experience of an individual into theoretical terms of disease and into a profession-specific taxonomy and nomenclature. •
Interpretation of the narratives of this individual experience should be a core task in medical prac tice. Neglect of the individual account of the per sonal experience may lead to an alienation of the patient or the caregiver.
The
saLutogenic viewpoints of
Antonowsky (1987) may
experience as proposed by Kleinmann (1988). Based on a critical appraisal of research outcomes, which have a tendency to focus on pathogenic factors, the introduc tion of a salutogenic perspective - which follows up questions as to why certain people stay healthy in spite of many stressors - has been suggested. salutogenic
perspective
emphasizes
various
aspects: •
merits attention in the
Loeser 1982, Pilowsky 1997). Behaviour may be con and sociocultural processes and will be influenced by earlier learning experiences. Fordyce (1982) suggests assessing pain and disability not only by verbal report and physical examination, but also by observing behaviour. In fact, it is argued that many health professionals observe and react to the behav iour of their patients without being explicitly aware of this (Fagerhaugh & Strauss 1977). Fordyce argues that humans and the complex behaviours they display can only be understood by considering their biomedical, genetic, psychological and environmental or social contexts. He suggests following up questions as to
why
certain behaviours take place rather than questioning which nociceptive processes lead to a certain kind of behaviour, thus leaving space for the interpretation of pain and disability from a pathobiological perspective as well as from emotional, cognitive and sociocultural viewpoints. Behavioural factors may be an essential element in the development of disability due to a pain experience (Philips & Jahanshani 1986, Klenermann 2004). Various
physiotherapists
suggest
integrating
cognitive-behavioural approaches in clinical practice, as many efforts will be undertaken to guide patients in changing their habits and (movement) behaviour (French 1988, Harding & Williams 1995, Lockwood 1996, Solomon 1996, Martinez et aI1997). In may be concluded that, in both medicine and physiotherapy, psychOSOcial aspects of pain, disability and illness (rightly) receive more attention now than before. However, it needs to be emphasized that the
certain people remain healthy and others get ill in
psychopathological processes or social problems. The
A sense of coherence
-
this appears to be an important
factor for successful coping with stressors and maintaining a sense of health.
states or disability are
not
necessarily indicators of
psychosocial aspects need to be considered as variables of the human experience and are more likely to be
contributing factors to ongoing pain and disability than causative ones (Kendall et aI1997).
Health and disease - these should be defined on two extreme ends of a dynamic continuum.
•
illness behaviour
presence of psychosocial variables in ongoing pain
the presence of certain stressors?
•
In particular,
more holistic biopsychosocial paradigm (Fordyce 1982,
Reflection on the basic viewpoints on health and disease which factors may be decisive as to why -
•
Schliffel et aI1998).
et al 1995, Pilowsky1997, V laeyen & Linton 2000, Waddell
complement the perspective of the individual illness
A
ence of health or wellbeing (Antonowsky 1987,
sidered as the result of biological, cognitive, emotional
and is dependent on what a society regards as
•
illness. Furthermore, the caregiver also seeks factors
Physiotherapy-specific paradigms
Following both pathogenic and saLutogenic paradigms, in
Although it appears that phYSiotherapists would read
which the caregiver seeks those factors which may
ily accept a biopsychosocial paradigm, it has been sug
lead to a move backwards towards an experience of
gested that this model should only be adopted within
Contemporary perspectives in physiotherapy practice
75 J
Figure
Person Subcellular
Tissue
in environment
Person
Movement continuum
knowledge of physiotherapy. The
in society
levels are interdependent, functions of one level influence movement
External factors
( ( (
4.1
theory: suggested model of body of
--
capacity of other levels. This model should incorporate all concepts of
--'___-i-- Internal factors __
physiotherapy practice. Reproduced
Individual/environment interface
by kind permission from Cott et al
(1995).
Micro Macro Continuum of movement
the specific framework of physiotherapy (Roberts
practice
According to Grant
(1995), a primary physiotherapy
paradigm may be defined in the maintenance and
1994, Grant 1995).
The need to formulate physiotherapy-specific para
restoration of function, in which clients are helped to
digms may be seen in the context of professionalization
return to an optimal functional activity and an enhanced
processes: it is argued that it is within physiotherapy's
appreciation of health and a healthy lifestyle.
own responsibility to identify physiotherapy-specific paradigms for clinical care, education and research,
Colt et al
(1995) have elaborated on Hislop's model
with the movement continuum theory of physiotherapy
which are required to be subjected to systematic study
(Fig.
(Tyni-Lenne
organ systems, body parts, the person in the envir
1989) in order to become an authority on physiotherapy's own body of knowledge (Parry 1991, Welti 1997).
4.1). Interrelated levels of molecules, cells, tissues,
onment and the person in the society are of influence on the movements of a person. It is recognized that external, social and cultural factors, as well as internal,
Physiotherapy paradigms: movement as the common denominator
physiolOgical and psychological factors will influence
It appears that, within phYSiotherapy, movement and its
and a movement potential, which ideally should be the
rehabilitation is considered the core of clinical prac tice and the common denominator to all concepts in phYSiotherapy, and various authors worldwide have contributed to this viewpoint. Hislop
(1975) proposed the formulation of a specific
paradigm for physiotherapy research within a concept of motion and pathokinesiology, in which motion was considered at different interrelated levels of cells, tis sues, organs, systems, persons and family. Sahrmann
(1993) argues that physiotherapists are
specialists in movement disorders, comparable to other medical specialists (e.g. cardiologists). She argues that movement should be considered as a specialized physio logical system just like all other systems. She recom mends
developing
a
classification
of
movement
dysfunctions and impairments as a basis for inclusion and exclusion criteria in physiotherapy research. Rothstein (1994) considers that physiotherapy should be in the domain of rehabilitation sciences and should enhance meaningful functioning in the lives of persons who seek the help of phYSiotherapists, while DeVries & Wimmers
(1997) argue that physiotherapy should be a
part of movement sciences.
the movement functions at each level of the movement continuum. Each level has a current movement capacity same. In this movement continuum all the different con cepts and methods of physiotherapy should find their place.
PROFESSIONAL DECLARATION S AN D THE MOVEMEN T PARADIGM The development of a specific movement paradigm in physiotherapy is increasingly reflected in the work of numerous professional associations in different countries. Their descriptions of the profession place
movement and movement functions attention (CSP
at the centre of
1990, CPA 1992, KNGF 1998, APTA
2001). The World Confederation of Physical Therapy also recommends following a movement paradigm and adheres to Cott et aI's movement continuum theory by pointing out that:
[Physiotherapy] is concerned with identifying and maximizing movement potential within the spheres of promotion, prevention, treatment and rehabilitation. This is achieved through interaction
76
MAITLAND'S PERIPHERAL MANIPULATION
Participation - social roles
Individual illness experience
Pathobiological processes Stages of tissue healing
connective tissue
viscera
Fi gure 4.2 Hengeveld
Model of ICF with the integration of a manual therapy specific taxonomy of impairment analysis. Adapted from
1999, with permission.
between physical therapist, patients or clients and caregivers, in a process of assessing movement potential and in working towards agreed objectives using knowledge and skills unique to physiotherapy.. . . It places full and functional movement at the heart of what it means to be healthy. wePT (1999, p. 7)
describe aspects of movement which cannot be directly observed with the regular clinical examination tools of the physiotherapist. Therefore, diagnosis in physiotherapy may be expressed in terms of movement dysfunctions using the levels of disability as described in the InternationaL Classification of Functioning, Disabilities and Health (ICF) (WHO 2001):
Physiotherapy diagnosis
Within the professionalization process and the declar ation of the specific body of knowledge, it has been debated over the last two decades that physiotherapists should make a specific diagnosis of the disorders they examine (Rose 1988, 1989; Sahrmann 1988; Guccione 1991; Delitto & Snyder-Mackler 1995; Wiarda et al 1998). The World Confederation of Physical Therapy takes a clear stance with regard to physiotherapy diagnosis and movement functions:
Diagnosis arises from the examination and evaluation and represents the outcome of a process of clinical reasoning. This may be expressed in terms of movement dysfunction or may encompass categories of impairments, functional limitations, abilities/ disabilities or syndromes. wePT (1999, p. 7) International Classification of Functioning, Disabilities and Health (ICFj
While the movement continuum theory (Cott et al 1995) eventually may become the theoretical model which underpins clinical practice and guides research efforts, in daily practice it may not be suitable for making a physiotherapy diagnosis, as the micro levels
•
Functions are the physiological or psychological
•
Body structures are anatomical parts of the body
functions of body systems
•
•
• •
•
•
such as organs, limbs and their components Impairments are problems in function or structure such as significant deviation or loss Activity is the execution of a task or action by an individual Participation is involvement in a life situation Activity limitations are difficulties an individual may have in executing activities Participation restrictions are problems an individual may experience in involvement in life situations EnvironmentaL and personal factors make up the physical, social and attitudinal environment in which people live and conduct their lives.
One suggestion is to incorporate the rCF in the basic taxonomy of physiotherapy and manual therapy prac tice (Hengeveld 1998, 1999) to allow follow-up of treat ment goals beyond impairment levels, as debated by Dekker et al (1993) and Van Baar et al (1998a). The analysis of impairments of movement function has been the specific domain of manual therapists. Figure 4.2 delineates a model in which manual ther apists can integrate their specific taxonomy of analysis
Contemporary perspectives in physiotherapy practice
Figure Physiotherapy process from a phenomenological perspective
4.3
A phenomenological
approach to the rehabilitatio n o f movement dysfunctions may guide p hysiotherapists i n a
Individual i1lnesl experience, behaviour
Experience of health maintaining behaviour
(Kleinmann 1988)
(Antonowsky 1987)
•
Movement sensitivity, activity intolerance
•
Impairments, activity limitations,
•
•
Illness behaviour (e.g. avoidance, help-seeking)
•
Suffering, distress
•
Pathobiological processes
t reatment objectives.
Symptoms, signs (Impairments) Trust. use of body, forgetting Body during activities
participation restrictions •
comprehensive planning of
•
•
Level of activity, participation Prevention/prophylactic measures awareness of use-of-self
•
Control: Knowing what to do/doing if recurrences occur (active coping
© Hengeveld 1999
strategies) - control over well being
of the components of movement impairment into a model of the ICF. This model may further serve in the definition of comprehensive treatment goals at all levels of disablement, in which the individual illness experience (Klemmann 1988) may determine the prior ities of goal setting at each level of disablement. In rehabilitation, the specific strengths of the different professions may be better utilized: for example, gener alist physiotherapists and occupational therapists have developed many skills in rehabilitation on the levels of activities and participation, whereas manual ther apists may give their special contribution to a team with the analysis and treatment of movement impair ments and pain.
The phenomenological approach to the movement paradigm
Within the movement paradigm, physiotherapists fre quently translate the individual illness experience (Klemmann 1988; see Biopsychosocial model above) of patients into their profession-specific taxonomy of movement dysfunctions and resources. From a phenom enological point of view physiotherapists may guide patients on the continuum as proposed by Antonowsky (1987) from 'dis-ease' to 'ease' or, in other words, physio therapists may guide patients towards a 'sense of health or wellbeing' and health-promoting behaviour with regard to movement function (Hengeveld 2003). In treatment planning, physiotherapists may 'think from the end' and consider the possible ideal state of movement functions if all treatment objectives could be achieved. In defining treatment goals with the patient, consider which aspects are missing in the
'ideal state' that could be followed up in treatment (Fig. 4.3): •
•
•
•
•
•
Which movement impairments should be improved, if an ideal state could be achieved? Which activities have to improve? Do any activities regarding participation need to be followed up? Does the patient seem confident (trusting) in moving the body in daily life? (If not, how can the manipulative physiotherapist guide the patient to the experience?) Does the patient move with an increased bodily awareness (and guarding) or seem to 'forget' the body during meaningful activities? Is the patient aware of any preventive measures and the way their body is used in daily life situations? Control - does the patient seem to have an adequate sense of control of the pain or wellbeing? If not, which measures should be undertaken? (See Appendix 2.)
Summary: paradigms and theoretical models
To summarize, the changing i nsights in paradigms, theoretical models and their consequences may be expressed in this concept of manipulative physiother apy as follows: •
•
The term 'nature of the person' and the specific frame of reference relate to the biopsychosocial paradigm, in which it is recognized that a patient's thoughts, beliefs, feelings and earlier learning processes may be important contributing factors to the disorder and need to be respected in treatment (Chapter 1). The 'art of manipulative physiotherapy' has con cerned itself principally with movement impairments.
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[ Fi gure 4.4 Theoretical aspects
Clinical aspects
ICD
ICF
(International Classification
(International Classification of
of Diseases)
Functioning, Disabilities and Health)
Biomedical diagnosis
Physiotherapy diagnosis:
Some of the current developments
of physiotherapy practice and research expressed in the 'brick wall' anal o gy.
Symptoms and signs of movement dysfunctions Commitment to patient:
Phenomenological perspective: illness experience and illness behaviour �� sense
of health or wellbeing and
health promoting behaviours with regards to movement functions
In the movement continuum theory it may find its place predominantly on the level of movement of 'body parts'. The treatment of these impairments with passive movement plays a central role in many movement disorders; however, physiotherapists have to consider if the treatment leads to improve ment of functioning on activity and participation. If this does not take place, appropriate interventions need to be taken (see Figure A2.1, Appendix 2). •
•
•
Physiotherapists increasingly assume 'movement', with all its dimensions, as a core commitment to patient care. The symptoms and signs which guide the therapeutic process are in fact symptoms and signs of movement dysfunctions and contribute to the specific physiotherapy diagnosis. Within the principle of 'commitment to the patient', a phenomenological approach to treatment may be followed with the concept of the illness experience. From this perspective, physiotherapists may guide patients with regard to movement from an 'individ ual illness experience and illness behaviour' towards an 'individual sense of health and health maintaining behaviours' (see Fig. 4.3). Some of the above-mentioned aspects may be expressed in the 'brick wall' analogy (Fig. 4.4).
THE PAIN REVOLUTION With the publication of the 'gate control theory' in 1965 (Melzack & Wall 1984) the traditional biomedical para digm seems to have been challenged. In this paradigm pain was considered as a symptom directly related to the extent of bodily damage, with the consequence that treatment was focused on removing or normalizing the underlying pathology of the pain. In the absence of
bodily damage the mind was assumed at fault and psy chopathology was inferred (Vlaeyen & Crumbed 1999). The gate control theory appears to have catalysed a shift towards a biopsychosocial paradigm in the research, assessment and treatment of pain, and pro posed that cortical processing was involved in the integration of both sensory-discrirninative and affec tive-motivational aspects of pain. The implication of this theory was that cognitive, emotional, behavioural, social and cultural dimensions were identified as essential con tributing factors to the pain experience of a person. From a neurophysiological perspective the gate control theory implied that pain was not only the result of nociceptive information ascending from peripheral structures but also that pain could be modulated by descending path ways in the central nervous system. This theory further proposed that pain could be a result of processing in neuronal networks rather than a consequence of tissue damage alone. However, it is argued that pain should be ascribed to diverse mechanisms of the nociceptive sys tem in neuronal networks rather than to a single neuro physiological pain mechanism (Cervero & Laird 1991) and to elements of neuroplasticity or learning processes (Loeser & Melzack 1999). Cervero and Laird (1991 ) suggested that to assess pain with its underlying neurophysiological pain mech anisms it is necessary to distinguish between: • • • •
nociceptive mechanisms peripheral neurogenic mechanisms central nervous system modulation autonomic nervous system influences.
The modulatory influence of the central nervous system on transmission of nociceptive impulses has received increasing attention in the physiotherapy literature, in which it is recommended that the central nervous system is viewed as an integrated cyclical system
Contemporary perspectives in physiotherapy practice
rather than a simple cause-and-effect system distin guishing between afferent and efferent aspects of func tion (Wright 1999b). For further reading see Gifford (1998a) and Butler (2000). Pain as a dynamic phenomenon
It is argued that the interpretation of neurophysiological pain mechanisms may be too linear and does not acknowledge the dynamics of the pain experience of a person suffiCiently. It is suggested that a pain experience often changes over time as a result of interactions between the illdividual, the environment and medical professionals (Delvecchio Good et al 1992) and also due to the increasing influence of cognitive, emotional and behavioural factors (Vlaeyen & Crombez 1999). An increasing sense of distress or suffering may contribute to the experience over time, if aspects such as a sense of helplessness, worthlessness and impaired self-esteem also start to play a role in the pain experience and dis ability (Corbin 2003). If the dynamics of a pain experi ence starts to change over time, there needs to be an explicit distinction between symptoms and signs of pain and disability. Furthermore, the interventions of a physio therapist have to be adapted with the incorporation of, for example, self-management and/or educational strategies. From a neurophYSiolOgical perspective different models are proposed in which the dynamics of a pain experience may be expressed. Gifford (1998b) with the mature organism model and Shacldock (1999) with the processing model suggest explaining the pain experience from the perspective that input to the central nervous system will be processed in the central nervous system, which consequently may influence output systems of the body. From a biological point of view, the brain or central nervous system may be seen as a discrimination centre which continuously scans the environment, the body and relevant past experiences (Gifford 1998b). Central nervous system processing may be influenced by biological factors, cognitive and emotional aspects, sociocultural meanings and previous learning experi ences. It is suggested that this processing of the central nervous system may be of major influence on efferent physiological systems, such as muscle tone, autonomic responses and endocrinological and immunological systems, as well as on behavioural reactions such as expression, movement or activities ('output mech anisms') (Gifford 1998b, Shacklock 1999). The role of movement in the treatment of pain
Over the last two decades of the 20th century many industrialized countries saw a dramatic rise in the number of individuals receiving compensation due to
pain-related disability (Waddell 2004). The changing insights on pain as well as the rise in the number of individuals with chronic pain have led to changes in paradigms regarding the treatment of pain. Within a cognitive-behavioural approach it is argued that disability due to pain pertains to performance behav iour (Fordyce 1997) and at times may be considered as a form of avoidance behaviour to activities or social con tacts (Philips 1987). It needs to be determined if the avoidance behaviour is adaptive and directly related to nociceptive processes or if it has become maladaptive due to cognitive and affective learning processes and sociocultural influences (Pilowsky 1997). However, in the presence of maladaptive behaviour, do not implicitly blame the patient, but take a multidimensional perspec tive in the treatment of pain and consider all possible influences in the assessment and treatment of patients in pain (Kendall et al 1997). Within this context, a favourable development regarding the specific role of physiotherapists in the medical world appears to have taken place: an increas ing number of papers have been published which focus on the role of movement in the treatment of pain and dis ability, in order to influence or prevent the (maladap tive) avoidance of activities and long-term disability due to pain: •
•
•
•
Fordyce (1995) suggests focusing on activity intol erance rather than on pain in the rehabilitation of many pain states. The terms mechanosensitivity and movement sensitiv ity should be used if movements provoke pain. The Paris Task Force describes the role of activity in the treatment of low back pain and suggests an approach of reduced activity rather than bed rest in acute pain states and that patients should be guided in resuming their full activity potential at an early stage (Abenhaim et aI2000). In the treatment of degenerative osteoarthritis, a dynamic approach is suggested by Bullough (1984), with a focus on normalizing joint mobility, muscu lar control, movement patterns and aerobic condi tion (Dieppe 1998). In fact exercise therapy has been found to have beneficial effects on pain and disabil ity in degenerative hip and knee osteoarthritis (Van Baar et aI1998b).
Some of the aforementioned publications describe activity or exercise therapy in the treatment of pain, implying a dominant role for active movements. However, if this refers to movement, rather than to activ ity or exercises, it may leave more room in clinical deci sion making for all forms of movement, as it is the
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[ opmlOn of the authors that both active and passive movement can assume their place in the treatment of many patients with pain and disability. Summary: the pain revolution
Symptoms and signs as described in the brick wall analogy in fact should relate to the multidimensional aspects of a pain experience. Physiotherapists should distinguish explicitly between the constructs of pain, disability and distress, define hypotheses with regard to these constructs and shape the treatment, communi cation and educational strategies accordingly. Over a short period of time after an acute nociceptive onset, cognitive and affective factors may start to play a role in the pain experience (VIaeyen & Linton 2000), which physiotherapists may address with, for example, con scious reassessment procedures, educational strat egies, communication and self-management strategies (Chapters 3 and 5, Appendix 2). Within this context a tendency to 'hands-off' treatment may be observed. However, the essence of manipulative physiotherapy as a hands-on profession and the power of therapeutic touch in the reintegrative role of bodily awareness and sense of self should not be underestimated (Rey 1995, Ledermann 1996, Van Manen 1998). The dynamic models as described by Gifford (1998b) and Shacldock (1999) may be an adequate learning and teaching tool for physiotherapy practice as they allow for explanations on the relevance of cognitive behavioural approaches, information strategies and the therapeutic relationship of physiotherapy practice. They may provide a framework for decision-making processes regarding the selection of physiotherapist directed interventions such as passive movement and the education of self-management strategies, bodily awareness and proprioception and gradual exposure to activities by, for example, medical training programmes or other forms of movement. With regard to primacy of clinical evidence, educa tional programmes as well as changes in therapeutic approaches based on insights of pain should lead to better functioning and wellbeing. Only by profound assessment procedures can the clinical evidence be delivered and these goals be achieved (Chapter 5).
RES E ARCH For some years, physiotherapy - like other health professions - has been under pressure to identify its added value to society and to justify its treatment methods by research processes. Within the profession alization process physiotherapists have increasingly
assumed their responsibility to conduct research which validates clinical practice. Currently, clinical practice seems characterized by an era of expert evaluation and evidence-based practice (Ritchie 1999) in which movement is increasingly becoming a core principle (Sahrmann 2002) as an expression of the specific body of knowledge of phYSiotherapists. In fact incorporating movement classifications as inclusion and exclusion criteria in phYSiotherapy-specific research has been proposed (Maluf et al 2000). Over the years a substantial body of publications has grown, supporting the use of both pas sive and active movement in many disorders (Chapter 2). Further within the ranks of physiotherapy, the debate has started as to which paradigms for clinical practice and research should be followed. It has been argued that within the art and science of physiother apy, science originally was concerned with the rational, deductive and measurable aspects of practice (quanti tative research) and the art as the intuitive, inductive and non-measurable part of practice (Shepard 1987). This approach to physiotherapy science as the sole contribution to the physiotherapy knowledge base has been questioned by many authors. Pratt (1989) argues that frequently physiotherapists tend to a more orthodox selection and presentation of what is seen as relevant areas of knowledge, i.e. an objective approach to clinical care, dealing with natural orders, probability, causality and experimental testing. However, daily practice is not related to an objective approach to patients: the setting, meanings and per sonal intentions play a relevant role in daily practice. With the application of predominantly biomedical knowledge, generated from an empirico-analytical paradigm, physiotherapists may have insufficient comprehension of the patient's subjective understand ing and experience of illness and their resulting behav ioural responses (Sim 1990). The practice of physiotherapy is more than the application of techniques - modalities of treatment and the clinical setting in which the technique is applied, together with other contextual factors are inte gral to the evaluation of the effectiveness of treatment. Physiotherapy research should therefore adhere to multiple paradigms and employ different approaches to research (Parry 1991, 1997). Ritchie (1999) considers that a pronounced emphasis on a scientific mission of bringing evidence may reduce the essence of the humanistic approach of health care. The input from personal, subjective dimensions has to be incorporated in research and clinical practice. The more traditional model of quantitative research may not be fully applicable to the clinical setting, and other forms of research (e.g. qualitative research) may be more responsive (Shepard 1987).
Contemporary perspectives i n physiotherapy practice
Within this debate, an increasing number of researchers recommend incorporating qualitative as well as quantitative research methods in physiotherapy research, in order to make a comprehensive contribu tion to the knowledge base of the profession in which theories and concepts can be generated as well as tested (Shepard 1987, Jensen 1989, Stone 1991, Shepard et al 1993, Parry 1995, Sim 1996, Smith 1996, Carpenter 1997). The following definition of research (DePoy & Gitlin 1998) underlines an open approach to research and the application of evidence-based practice, which on the one hand should be inductive in generating theories and, on the other, deductive in questioning and testing theories:
Research is a group of multiple, systematic strategies that generate knowledge about human behaviour, human experience, and human environments in which the thought and action processes of the researcher are clearly specified so they are logical, understandable, confirmable and useful. Evidence-based practice
Evidence-based practice is defined by Sackett et al as:
The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. It is emphasized that evidence-based medicine is not 'cook book' medicine and the clinician needs a mastery of patient interviewing and physical examination skills (Sackett et al 1998, pp. 2, 3, IX). Although compliance with evidence-based practice is highly recommended, at times it may put clinicians in a dilemma in making decisions based on the 'best avail able external clinical evidence'. Part of the dilemma is caused by the fact that factors other than selecting treat ment procedures play an important role in providing optimal care. Schon (1983) argues that concern exists about the increasing gap between research-based knowledge and the professional knowledge that guides everyday activities in which practitioners need to interpret incomplete and ambiguous information in order to make decisions with regard to practice. In the rehabilitation of painful movement disorders the way that treatment is applied, the communication between the physiotherapist and the patient and aspects such as motivation, beliefs, learning experiences, collab oration, education, setting, individual concerns and so
on may influence the results of the treatments applied (Linton 1998). The inclusion and exclusion criteria for many stud ies form another dimension of the dilemma. Physio therapists may not always recognize their 'own' patients as they are presented in clinical studies: inclu sion criteria may be based on pathobiological diag noses rather than on movement disorders (Maluf et al 2000) or outcome measures used in the studies may not reflect the relevant clinical outcome measures of pain and movement function of the phYSiotherapist (Jones & Higgs 2000). Above all, many of the problems encountered in daily physiotherapy practice are multicomponential and multidimensional movement disorders, whereas many studies deal with problems which are unistruc tural in nature in which it is assumed that the prob lems have a single cause and need a single treatment approach. As a consequence of these dilemmas physiother apists are frequently left to their own devices in making the best decisions with and for their patients in daily practice. They often need a balanced and pragmatic approach towards clinical practice and results from 'evidence-based practice'. Not only will physiother apists need a mastery of patient interviewing and physical examination skills (Sackett et al 1998), but they will also need a proficiency in the application of various treatments,
including communication abilities and clinical reasoning skills. Only the application of consequent reassessment procedures allows for reflection on the decisions made with regard to treatment, be they arriving from the experiential knowledge base or from a propositional knowledge base as evidence-based research findings. Only the clinical results will indicate if the suggestions of the 'best evidence' are indeed applicable to the indi vidual patient (Chapter 5). Nevertheless, evidence-based practice is an essen tial skill to enhance clinical practice; however, it can only be applied successfully with an increased aware ness of clinical reasoning processes (Jones & Higgs 2000) and consequent assessment procedures. Here evidence-based practice correlates with one of the main pillars of this concept of physiotherapy: the primacy of clinical evidence (Wells 1996). Different research methods : quantitative and qualitative research
As stated above, various researchers recommend fol lowing different paradigms in research and applying both quantitative and qualitative research methods to underpin clinical practice. In particular, qualitative
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research methods may make implicit approaches, meanings and assumptions explicit, which in later stages may be put under the scrutiny of quantitative research methods. Some authors claim that clinical practice 'per defin ition' would be lagging behind science (Van den Ende 2004). Frequently this may be the case with the applica tion of insights from evidence-based practice (Linton 1998). However, insights or unusual observations from numerous clinical situations have led to meaningful research questions, which later could be generalized in overall practice (e.g. application of neurodynamics). In such cases clinical practice may walk ahead of science. In fact, it is noted by Parry (1991, p. 437) that many physiotherapists who contributed to current clinical practice employed forms of qualitative research with out expliCitly referring to this:
Current practice owes its diversity and vitality to qualitative observation....Bobath, Knott, Maitland and others who have contributed in no small amount to the knowledge and practice of physiotherapy went through a process, which is characteristic of ethnog raphy, to develop their concepts and techniques.... observed patients and own handling systematically, constantly analysing the effects, . . . keeping a written record, making comparisons with other records, and using insights from experience to modify techniques .. . .In this way physiotherapy can run ahead of science for decades before research in the biomedical sciences begins to provide objective supporting evidence. In the interim many innovations will be rejected as well as disseminated according to practitioners' judgement of their effectiveness. In order to allow for future innovative practice and not just to scrutinize existing practice, in times to come physiotherapy practice will need clinicians with a bal anced approach to the application of research findings and an open mind to clinical presentations which seem at odds with the current actual theoretical models and clinical frameworks. A critical testing of research find ings is needed in daily encounters with patients. This requires precise observational abilities, critical self reflection, lateral thinking, profound assessment and consequent reassessment procedures, and a refined and systematic documentation system which can describe both regular and uncommon clinical observa tions in sufficient detail.
CLINICAL REASONING Clinical reasoning undoubtedly has always been employed by clinicians; however, for the past three
decades clinical reasoning has received more attention in educational and research processes. A conscious con sideration of clinical reasoning processes has been rec ognized as a critical skill, which is central to the practice of professional autonomy (Higgs & Jones 2000) and enables profound clinical practice (Elstein 1978). Clinical reasoning is defined in various ways, for example, 'the thinking and decision-making processes associated with clinical practice' (Higgs & Jones 2000). The anthropologist Mattingly and occupational ther apist Fleming take a more phenomenological perspec tive in which they explain that clinical reasoning is mainly a tacit, half-conscious, complex problem solving process. In this process not only the medical diagnosis, but also the patient with his personal illness experience, is at the centre of attention. It is more than applied science; it is more likely 'applied phenomen ology'. During a therapeutic session a clinical judgement is made about causes, ways to treat and how to inte grate the patient actively in the rehabilitation process. The therapist may not always be explicitly aware of all the decisions made during this process (Mattingly & Fleming 1994). Physiotherapists employ highly complex clinical reasoning processes in which various paradigms to practice and different forms of clinical reasoning are followed (Hengeveld 2000): •
•
•
In some instances it will be a form of biomedical reasoning, in which the physiotherapist considers pathobiological processes mainly to detect precau tions and contraindications to treatment. Within the specific physiotherapy movement para digm, physiotherapists will follow a pathogenic perspective in which any abnormalities to move ment are examined. In the salutogenic perspective, measures are under taken or taught to maintain and promote health with regard to movement functions of an individual.
Various forms of clinical reasoning are described: •
• •
considering movement impairments, activity limitations and participation restrictions and their contributing factors, as well as pathobiological processes.
Diagnostic reasoning
-
Theoretical reasoning theory guiding clinical decisions. -
Procedural reasoning thinking about disease or dis ability and deciding on the procedures of assess ment and treatment which may be employed to restore the patient's movement functions. In exami nation and treatment multiple hypotheses may be generated based in cue acquisition and tested by -
Contemporary perspectives in physiotherapy practice
83
J reassessment procedures. Decisions may be based on hypotheses generated or the recognition of clini cal patterns. In manipulative physiotherapy prac tice this is probably one of the best known forms of clinical reasoning (Chapter 5). •
Interactive reasoning - takes place during the direct encounters between therapist and patient. It may be employed to: - understand the patient better - convey trust and acceptance - engage the patient in the treatment session - understand the disability from the patient's perspective - individualize treatment to the specific needs and abilities of the patient - use humour to relieve tension - construct a shared language of actions and meanings - inform the patient about the specific procedures and reasons for these in examination, treatment and reassessment (see also Chapter 3).
•
•
Conditional reasoning - more likely to be used by therapists with a phenomenological approach to practice. It is being employed in a wider social and temporal context. The therapist thinks about the overall condition of the patient, including the per sonal illness experience and context, and considers how the future condition and the patient's life might change as a result of the selected interventions. In treatment planning and during treatment, the thera pist interprets the meaning of the problem in the context of a possible future for the patient. Narrative reasoning - 'reasoning by telling stories'. Various forms of narrative reasoning are described: - the patient gives an account of the individual story, rather than being controlled by procedural questions; the therapist attempts to understand the patient's individual story ('narrative') (see also 'Psychosocial assessment', Chapter 5) the encounter between therapist and patient unfolds like a story, which may make an observer curious about how it unfolds later on therapists engage in story telling among col leagues, in order to make sense of the individual illness experience of their patients therapists may use stories to educate patients in a broader context, the therapist may enter the life story of the pa tient. Over the years of clinical experience clinicians seem to encapsulate their theoretical knowledge and may be strongly guided in the decision-making processes by the stories which they have experienced
with individual patients ('illness scripts') (Schmidt & Boshuyzen 1993). • • • • •
Practical reasoning Ethical reasoning Pragmatic reasoning Collaborative reasoning Teaching as reasoning
(Adapted from: Mattingly 1991 , Ryan 1995, Munroe 1996, Higgs & Jones 2000.) Clinical reasoning skills and science have become important aspects in professional declarations (WCPT 1999) and clinical reasoning is referred to regularly throughout this text. Clinicians being trained in this concept of manipu lative physiotherapy may recognize aspects of hypoth eses in inductive and deductive procedural clinical reasoning, as it has been one of the principles of the brick wall analogy to formulate hypotheses about the condition of the patient. Furthermore, some elements of interactive clinical reasoning may be recognized, following the emphasis on developing communication skills to enhance the exchange of information and understanding (Maitland 1986). However, it is essen tial to make the implicit processes which guide clinical decisions explicit, in order to guarantee independent practice Oones 1995), to guide novices on the path to expertise (Ryan 1995) and to support the overall devel opment of the profession (Grant 1995). It is recommended that physiotherapists consciously reflect on the individual clinical reasoning processes and on the hypotheses being generated, modified and tested during the therapeutic process (Grant et al 1988). Categorization of the hypotheses generated may enhance efficiency and the recollection of relevant information (Thomas-Edding 1987). Within this con cept of manipulative physiotherapy, therapists are encouraged to reflect on their hypotheses in some crit ical phases as well as in the planning stages of the thera peutic process, as described in Chapters 3 and 6. Clinical reasoning may be summarized as 'wise action' Oones 1997), in which phYSiotherapists endeav our to integrate three areas into their deCision-making processes (Butler 2000): 1. 2.
the best of science the best of current therapies with good assessment procedures and varied treatment strategies
3. the best of the patient-therapist relationship, with a client-centred approach with empathy, unconditional regard and genuineness (Rogers 1980), communica tion, educational strategies and an awareness of the possibilities of a cognitive-behavioural approach to the overall therapeutic process (Chapter 3).
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It can be concluded that clinical reasoning processes support the professionalization process of physiother apy, as summarized in the following quote by Grant (1995, p. 6):
Physiotherapy is both [an art and a science), and paradigms by their very definitions allow for both the art of clinicaL practice and the deveLopment of theory underLying such art through clinicaL reasoning and research, to develop the science of physiotherapy. CONCLUSION It has been acknowledged that Maitland - with the unfolding of the principles as outlined in this book has made a significant contribution to the develop ment of the declarative knowledge and identity of physiotherapy (Refshauge & Gass 1995). The Maitland Concept has progressed into one that meets the demands of current times as well as one that incorpo rates rather than excludes new methods and tech niques of assessment and treatment, provided they prove to be clinically valid (Wells 1996). The current era in physiotherapy seems to be determined by (biopsy chosocial) movement paradigms guiding the specific body of knowledge of physiotherapists, in which
evidence-based practice, clinical reasoning and vari ous forms of research play an important role in both research and clinical practice. Changing insights in the factors contributing to the pain experience of patients challenge physiotherapists to reflect upon their habit ual approaches to clinical practice and to integrate cognitive-behavioural perspectives and educational strategies into the art of manipulative physiotherapy. Nevertheless, it may be summarized that the unique approach to clinical practice with the principles as worked out by Maitland more than four decades ago still seems applicable at the beginning of the 21st century. It may be appropriate to conclude with the following quote from Professor Lance Twomey, Vice Chancellor, Professor of Physiotherapy, Curtin Univer sity of Technology, Perth, Australia:
Maitland's emphasis on very carefuL and comprehensive examination Leading to the precise application of treatment by movement and followed in turn by the assessment of the effects of that movement on the patient, forms the basis for the modern clinical approach. This is probabLy as close to the scientific method as is possible within the clinical practice of physical therapy and serves as a modeL for other areas of the profession. Twomey in Foreword to Refshauge & Gass (1995)
References Abenhaim, L., Rossignol, M., Valat, J. P. et a1. 2000. The role of activity in the therapeutic management of back pain. Report of the International Task Force on Back Pain. Spine, 25, 15-33S Antonowsky, A. 1987. The salutogenic perspective: towards a new view of health and illness. Advances, Institute for the Advancement of Health, 4, 47-55 APTA. 1988. Definitions of House of Delegates. Alexandria, VA: American Physical Therapy Association APTA. 2001. Guide to Physical Therapist Practice. Alexandria, VA: American Physical Therapy Association Barclay, J. 1 994. In Good Hands - The History of the Chartered Society of Physiotherapy 1 894-1994. Oxford: Butterworth Heinemann. Belanger, A. 1998. Confused identity hurts the image of physiotherapy. Physiotherapy Canada, 50, 245-247 Bullough, P. 1984. Osteoarthritis: pathogenesis and aetiology. British Journal of Rheumatology, 23, 166-169 Butler, D. 2000. The Sensitive Nervous System. Adelaide: NOr Group Carpenter, C. 1997. Conducting qualitative research in physiotherapy. A methodological example. Physiotherapy, 83, 547-552 Cervero, F. & Laird, J. M. A. 1991. One pain or many pains? A new look at pain mechanisms. News in Physiological Sciences, 6, 268-273
Corbin, J. M. 2003. The body in health and illness. Qualitative Health Research, 13, 256-267 Cott, C. A., Finch, E., Gasner, D. et al. 1995. The movement continuum theory for physiotherapy. Physiotherapy Canada, 47, 87-95 CPA. 1992. Description of Physiotherapy. Toronto: Canadian Physiotherapy Association CSP. 1 990. Standards of Physiotherapy Practice. London: The Chartered Society of Physiotherapy Dekker, J., van Baar, M. E., Curfs, E. C. & Kerssens, J. J. 1993. Diagnosis and treatment in physical therapy: an investi gation of their relationship. Physical Therapy, 73, 568-580 Delitto, A. & Snyder-Mackler, L. 1995. The diagnostic process: examples in orthopedic physical therapy. Physical Therapy, 75, 203-211 Delvecchio Good, M. J., Brodwin, P. E., Good, B. J. & Kleinmann, A., eds. 1 992. Pain as Human Experience. An Anthropological Perspective. Berkeley: University of California Press DePoy, E. & Gitlin, L. 1998. Introduction to Research. Understanding and Applying Multiple Strategies. St. Louis: Mosby De Vries, C. D. L. & Wirnmers, R. H. 1997. Is fysiotherapie gevolgengeneeskunde? Fysiopraxis, 6, 10-13 Dieppe, P. 1998. Osteoarthritis: time to shift the paradigm. BMt 318, 1 299-1300
Contemporary perspectives in physiotherapy practice
Elstein, A., Shulman, L. S. & Sprafka, S. A. 1978. Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, MA: Harvard University Press Engel, G. L. 1977. The need for a new medical model: a challenge for biomedicine. Science, 176, 129-136 Fagerhaugh & Strauss (1977) quoted by French, S. 1994. Psychosocial Aspects of Physiotherapy. Oxford: Butterworth Heinemann Ferrari, R & Russel, A. S. 1999. Whiplash: heading for a higher ground. Spine, 24, 97-98 Fordyce, W. E. 1982. A behavioural perspective on pain. British Journal of Clinical Psychologlj, 21, 3 1 3-320 Fordyce, W. E. 1995. On pain, illness and disability. Journal of Back and Musculoskeletal Research, 5, 259-264 Fordyce, W. E. 1997. On the nature of illness and disability. Clinical Orthopaedics and Related Research, 336, 47-51 French, S. 1988. History taking in the physiotherapy assessment. Physiotherapy, 74, 158-160 Gifford, L. 1998a. Pain, the tissues and the nervous system: a conceptual model. Physiotherapy, 84, 27-36 Gifford, L., ed. 1998b. The mature organism model. In Topical Issues in Pain - Whiplash: Science and Management. Fear Avoidance Beliefs and Behaviour. Adelaide: NOr Press Grant, R 1995. The pursuit of excellence in the face of constant change. Physiotherapy, 81, 338-344 Grant, R, Jones, M. & Maitland, G. 1988. Clinical decision making in upper quadrant dysfunction. In Physical Therapy of the Cervical and Thoracic Spine, ed. R Grant. New York: Churchill Livingstone Guccione, A. 1991. Physical therapy diagnosis and the relationship between impairments and function. Physical Therapy, 71, 499-504 Harding, V. R & Williams, A. C. d. C. 1995. Extending physiotherapy skills using a psychological approach: cognitive-behavioural management of chronic pain. Physiotherapy, 81, 681-688 Hengeveld, E. 1998, 1999. Gedanken zum Indikationsbereich der Manuellen Therapie. Part 1, Part 2. Manuelle Therapie, 2, 176-181; 3, 2-7 Hengeveld, E. 2000. Psychosocial Issues in Physiotherapy: Manual Therapists' Perspectives and Observations. MSc Thesis. London: Department of Health Sciences, University of East London Hengeveld, E. 2003. Das biopsychosoziale Modell. Angewandte Physiologie, Band 4. Schmerzen Verstehen und Beeinflussen, ed. F. v.d. Berg, Kapitel 1.4. Stuttgart: Thieme Higgs, J. & Jones, M., eds. 2000. Clinical Reasoning in the Health Professions, 2nd edn. Oxford: Butterworth Heinemann Hislop, H. J. 1975. The not-so-impossible dream. Physical Therapy, 55, 1069-1080 Holroyd, K. A., Malinoski, P., Davis, K. M. & Lipchik, G. L. 1999. The three dimensions of headache impact: pain, disability and affective distress. Pain Forum, 80, 425-431 Hullegie, W. 1995. Fysiotherapie, een Wetenschapstheoretische en VakJilosoJische Analyse. Utrecht: De TIjdstroom Jensen, G. M. 1989. Qualitative methods in physiotherapy research: a form of disciplined inquiry. Physical Therapy, 69, 492-500
Jones, M. 1995. Clinical reasoning and pain. Manual Therapy, 1, 1 7-24 Jones, M. 1997. Clinical reasoning: the foundation of clinical practice. Part 1. Australian Journal of Physiotherapy, 43, 167-171 Jones, M. & Higgs, J. 2000. Will evidence-based practice take the reasoning out of practice? In Clinical Reasoning in the Health Professions, ed. J. Higgs & M. Jones. Oxford: Butterworth-Heinemann Kendall, N. A. S., Linton, S. J., Main, C. J. et al. 1997. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Wellington, New Zealand: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee Kleinrnann, A. 1988. The Illness Narratives - Suffering, HeaLing and the Human Condition. New York: Basic Books Klenermann, L., Slade, P. D., Stanley, 1. M. et al. 1995. The prediction of chronicity in patients with an acute attack of low back pain. Spine, 20, 478-484 KNGF. 1992. Visie op Fysiotherapie. Amersfoort: Koninklijk Nederlands Genootschap voor Fysiotherapie KNGF. 1998. BeroepsproJiel Fysiotherapeut. Amersfoort/Houten: Koninklijk Nederlands Genootschap voor Fysiotherapie/Bohn Stafleu van Loghum Koke, A. J. A. 1997. Andere aanpak lage rugpijnklachten. Fysiopraxis, 8, 16-18 Kuhn, T. 1962. The Structure of Scientific Revolutions. Chicago: University of Chicago Press Ledermann, E. 1996. Fundamentals of ManuaL Therapy PhysioLogy, Neurology and Psychology. New York: Churchill-Livingstone Linton, S. 1998. In defence of reason. Meta-analysis and beyond in evidence-based practice. Pain Forum, 7, 46-54 Lockwood, S. 1996. How can physiotherapists influence chronic pain behaviour negatively and positively? New Zealand Journal of Physiotherapy, 13-16. Loeser, J. D. 1982. Chronic Low Back Pain. New York: Raven Loeser, J. D. & Melzack, R 1999. Pain: an overview. Lancet, 353, 1607-1609 Maitland, G. D. 1986. Vertebral Manipulation, 5th edn. Oxford: Butterworth-Heinemann Maitland, G. D. 1995. The development of manipulative physiotherapy. S VMP B ulletin, 10, 3-5 Maluf, K., Sahrmann, S. & Van Dillen, L. R 2000. Use of a classification system to guide nonsurgical management of patients with low back pain. Physical Therapy, 80, 1097-1111 Martinez, A., Simmonds, M. J. & Novy, D. M. 1997. PhYSiotherapy for patients with chronic pain: an operant behavioural approach. Physiotherapy Theory and Practice, 13, 97-108 Mattingly, C. 1991. What is clinical reasoning? American JournaL of OccupationaL Therapy, 45, 998-1005 Mattingly, C. & Fleming, M. 1994. Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice. Philadelphia: F. A. Davis Melzack, R & Wall, P. 1984. The Challenge of Pain. Harmondsworth: Penguin
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[ Moon, M. 1990. Rehabilitation and chronic musculoskeletal pain: a bio-psychosocial approach. New Zealand Journal of Physiotherapy, 4, 23-27 Munroe, H. 1996. Clinical reasoning in occupational therapy. British Journal of Occupational Therapy, 5, 196-202 NPl. 1997. 'Evidence-based' paramedische zorg. Een balans tussen 'consensus based evidence' en 'research based evidence'. Issue 4, 44 Parry, A. 1991. Physiotherapy and methods of inquiry: conflict and reconciliation. Physiotherapy, 77, 435-439 Parry, A. 1995. Ginger Rogers did everything Fred Astaire did backwards and in high heels. Physiotherapy 81, 310-319 Parry, A. 1997. New paradigms for old: musing on the shape of clouds. Physiotherapy, 83, 423-433 Philips, H. C. 1987. Avoidance-behaviour and its role in sustaining chronic pain. Behaviour Research and Therapy, 25, 273-279 Philips, H. C. & Jahanshani, M. 1986. The components of pain behaviour. Report. Behaviou r Research and Therapy, 24, 117-124 Pilowsky, I. 1997. Abnormal Illness Behaviour. Chichester: John Wiley Pratt, J. W. 1989. Towards a philosophy of physiotherapy. Physiotherapy, 75, 114-120 Refshauge, K. & Gass, E. 1995. Musculoskeletal Physiotherapy. Oxford: Butterworth Heinemann Rey, R 1995. The History of Pain. Cambridge, MA: Harvard University Press Ritchie, J. 1999. Using qualitative research to enhance evidence-based practice of health care providers. Australian Journal of Physiotherapy, 45, 251-256 Roberts, P. 1994. Theoretical models of physiotherapy. Physiotherapy, 80, 361-366 Rogers, C. R 1980. A Way of Being. Boston: Houghton Mifflin
Rose, S. 1988. Musing on diagnosis. Physical Therapy, 68, 1665 Rose, S. 1989. Physical therapy diagnosis: role and function. Physical Therapy, 69, 535-537 Rothstein, J. 1994. Disability and our identity. Physical Therapy, 74, 375-378 Ryan, S. 1995. The study and application of clinical reasoning research. British Journal of Therapy and Rehabilitation, 2, 265-271 Sackett, D., Richardson, W. S., Rosenberg, W. & Haynes, R B. 1998. Evidence-based Medicine - How to Practice and Teach EBM, 2nd edn. Edinburgh: Churchill Livingstone Sahrmann, S. 1988. Diagnosis by the physical therapist a prerequisite for treatment. Physical Therapy, 68, 1703-1706 Sahrmann, S. 1993. Movement as a Cause of Musculoskeletal Pain. Congress Proceedings of MPAA, Perth, Australia Sahrmann, S. 2002. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby Schmidt, H. & Boshuyzen, H. 1993. On acquiring expertise in medicine. Educational Psychology Review, 5, 205-221 Schon, D. A. 1983. The Reflective Practitioner. How Professionals Think in Action. Aldershot: Arena
Schiiffel, w., Brucks, U. & Johnen, R, eds. 1998. Handbuch der Salutogenese - Theorie und Praxis. Wiesbaden: UListein Medical Shacklock, M. 1999. Central pain mechanisms: a new horizon in manual therapy. Australian Journal of Physiotherapy, 45, 83-92 Shepard, K. E 1987. Qualitative and quantitative research in clinical practice. Physical Therapy, 67, 1891-1894 Shepard, K. E, Jensen, G. M., Schmoll, B. J. et al. 1993. Alternative approaches to research in physiotherapy: positivism and phenomenology. Physical Therapy, 73, 88-101 Sim, J. 1990. The concept of health. Physiotherapy, 76, 423-428 Sim, J. 1996. Focus groups in physiotherapy evaluation and research. Physiotherapy, 82, 189-198 Smith, S. 1996. Ethnographic inquiry in physiotherapy research. Part 1, Part 2. Physiotherapy, 82, 342-352 Solomon, P. E. 1996. Measurement of pain behaviour. Physiotherapy Canada, 48, 52-58 Stone, S. 1991. Qualitative research methods for physiotherapists. Physiotherapy, 77, 449-452 Teasel, R W. & Merskey, H. 1997. Chronic pain and disability in the workplace. Pain Forum, 6, 228-238 Thomas-Edding, D. 1987. Clinical Problem Solving in Physical Therapy and its Implications for Curriculum Development. Proceedings of the 10th International Congress of the World Confederation of Physical Therapy, Sydney, Australia Turk, D. c., Sist, T. c., Okifuji, A. et aJ. 1998. Adaptation to metastatic cancer pain: role of psychological and behavioural factors. Pain, 74, 247-256 Tyni-Lenne, R. 1989. To id �ntify the physiotherapy paradigm: a challenge for the future. Physiotherapy Theory and Practice, S, 169-170 Van Baar, M. c., Dekker, J. & Bosveld, W. 1998a. A survey of physical therapy goals and interventions for patients with back and knee pain. Physical Therapy, 78, 33-42 Van Baar, M., Dekker, J. & Oostendorp, R. A. 1998b. The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial. Journal of Rheumatology 25, 2432-2439 Van den Ende, E. 2004. Editorial: Van kloof tot greppel. Nederlands Tijdschrift voor Fysiotherapie, 114; 1 Van Manen, M. 1998. Modalities of body experience in illness and health. Qualitative Health Research, 8, 7-24 Vlaeyen, J. & Linton, S. 2000. Fear avoidance and its consequences in chronic pain states: a state of the art. Pain, 85, 317-332 Vlaeyen, J. w. S. & Crombez, G. 1999. Fear of movement/(re)injury, avoidance and pain disability in chronic low back pain patients. Manual Therapy, 4, 187-195 Waddell, G. 1987. A new clinical model for the treatment of low back pain. Spine, 12, 632-644 Waddell, G. 2004. The Back Pain Revolution, 2nd edn. Edinburgh: Churchill Livingstone
Contemporary perspectives in physiotherapy practice
WCPT. 1999. Description of Physical Therapy. London: World Confederation of Physical Therapy Wells, P. 1996. The Maitland Approach to the Assessment and Treatment of Neuro-musculo-skeletal Problems. IFOMT '96 The 6th International Conference, Lillehammer, Norway. Lillehammer, Norway: IFOMT Welti, S. R. 1997. Massage und HeilgtjYnnastik in der ersten Hiilfte des 20. Jahrhunderts. Sempach: Schweizerisches Rotes Kreuz (SRK), Schweizerischer Physiotherapeuten Verband (SPV)
WHO. 2001. ICF - International Classification of Functioning, DisabilihJ and Health. Geneva: World Health Organization Wiarda, v., Heerkens, Y., Vogels, E. M. H. M. et al. 1998. Project fysiotherapeutische diagnose. Fysiopraxis, 3, 27-29 Wright, A. 1999a. Editorial. Manual Therapy, 4, 185-186 Wright, A. 1999b. Recent concepts in the neurophysiology of pain. Manual Therapy, 4, 196-202
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Chapter
5
Principles of assessment
THIS CHAPTER INCLUDES: •
Key words for this cha pter
•
Glossary of terms for this cha pter
•
The physiotherapy process assessment procedures to monitor the therapeutic process
•
In itia I assessment - aims
•
Reassessment
•
•
Assessment d u ring treatment -
development a n d recognition,
interventions
prognosis, i n teractive a n d
throughout the physiotherapy
•
Aspects of clinical reasoning
process.
science - hypotheses generation a n d testing, clinical pattern
retrospective assessment, a nalytical assessment, clinical reason i ng,
further than assessment. Assessment cou l d be performed as a mechanical process to prove the value of a technique. An alytical assessment im plies a nalysing one's thoughts about all aspects of the patient's disorder, treatment decisions a n d i nteractions to arrive at clearly defined a nswers. As well as enforced discipline, it requires an agile, sceptical a n d methodical mind. It involves the process of 'think', 'plan' and 'execute' (to) 'prove'. Assessment - i n cludes all proced u res which are undertaken to mon itor
Psychosocial assessment
Final a n alytical assessment
KEY WORDS
Analytical assessment - goes a stage
•
•
Assessment, reassessment,
GLOSSARY OF TERMS
n a rrative reasoning
Retrospective a nd prospective assessment
the therapeutic process t h roughout
psychosocial assessment.
Final analytical assessment -
all encounters between the
u nderta ken towa rds the end the
physiothera pist a n d the patient.
treatment series to reflect o n the
Assessment proced u res do not
therapeutic a n d educational
stop after the first exa mination
process, to determine the c u rrent
a t initial consultations in which
state inclu ding the effect of self
the physiothera pist comes to a
m a nagement strategies a n d to
diagnosis of the movement
make a prognosis a n d u ndertake
disorder of the patient a n d
interventions to enha nce long-term
develops collaboratively with the patient a treatment plan assessment is an ongoing
com pliance. Initial assessment - takes place in the first session(s) a n d inclu des
a nalytica l process t h roughout
su bjective and physical
all therapy sessions.
exa minations a n d first
Assessment during the application
reassessment procedu res. Scope:
of therapy - determines if
finding ca uses of and contributing
treatment objectives are being
factors to the movement d i sorder,
ach ieved and that n o u ndesired
determining a n y preca utions
side-effects occu r.
and contra i n d ications to
90
M A ITLAND'S PER IPH E R AL M A N IP U LATION
examination a n d treatment
Psychosocial assessment - an
assessment may give more insights
procedures, determining treatment
i n tegral part of the overa l l
into the world of the individ ual
o bj ective(s) and selecting
physiotherapy assessment. Th rough
illn ess experience of the patient
mea ningful interventions, actively
attentive l i stening to key words,
and may contribute to a
i n tegrating the patient in the
carefu l observation of key gestures
multidimensional a p proach to
process. Progressive assessment -
and asking deliberate qu estions it
trea tment.
is possible to ascertain w hether
Reassessment procedures - need to
retrospective a n d prospective
there a re a ny cognitive, affective
be u n dertaken regula rly in each
assessments are u n d e rtaken in
or sociocultural processes a n d
session to monitor the effects of
addition to the session - by-session
behavioural aspects ('yellow flags')
the treatm ent procedures.
assessments to determine the
that may hinder the return to full
overall effects of treatment.
function. In fact, psychosocial
INTRODUCTION As pointed out in the first chapter of this book, assess ment is one of the cornerstones of this concept of physiotherapy. Analytical assessment (evaluation) encompasses observation, judgement and reflection. It includes all procedures which are undertaken to moni tor the therapeutic process throughout all encounters between the physiotherapist and the patient. It is emphasized that assessment procedures do not stop after the first examination at initial consultation in which the physiotherapist comes to a diagnOSiS of the patient's movement disorder and develops collabora tively with the patient a treatment plan. During all ses sions the physiotherapist should explore, in cooperation with the patient, if and how the treatment goals are gradually being achieved. The selected treatment interventions - be they mobilizations, manipulations or other forms of physiotherapy practice - will be care fully monitored as to their effects and, if needed, the therapy will be adjusted to the actual situation of the patient. Assessment and treatment procedures cannot be viewed separately: assessment procedures have an automatic transition into treatment procedures and vice versa (Fig. 5.1). The therapeutic process is an expression of often complex, highly tacit clinical reasoning processes (Mattingly 1991, Higgs & Jones 1995) in which many different decisions need to be made and wherein the physiotherapist usually engages in vari ous forms of clinical reasoning at the same time (Edwards 2000). Although it will often be useful for beginners in the field to learn set procedures of assessment and planning of subsequent sessions, it is emphasized that the therapeutic process is a 'process of continuous improvisation, in which clinicians need to be able to
Physiotherapy process Session 1
Last Session
Therapeutic Relationship Figure 5.1
Assessment and treatment procedures are distinct
but inseparable components in the physiotherapy process. The whole process is carried by the development of a therapeutic relationship and communication. Reproduced by kind permission from Hengeveld
(2000).
simultaneously perceive and interpret multiple physi cal, psychological and social patient cues and adjust their treatment and responses to the evolving patient session. This form of dynamic interaction requires more than strong biomedical knowledge' Gones 1995). The sometimes delicate process in which the patient is guided from an 'individual illness experience with illness behaviours' towards an experienc€ of 'individ ual health and health-maintaining behaviours with regard to movement functions' (Hengeveld 2003), and in which the therapist integrates insights from 'evidence-based practice' (Chapter 4), is best governed by assessment procedures and continuous reflection. In contemporary descriptions of the physiotherapy profeSSion, examination and evaluation procedures are declared to be integral parts of the physiotherapy process (CSP 1990, KNGF 1998, WCPT 1999, APTA 2001 ). Regrettably in some European countries, phys iotherapists still have an auxiliary status in which they are expected to perform treatments as ordered by
Princip les of assessment
another authority in the treatment team and to leave out their profession-specific assessments as a basis for clinical decision making. Nevertheless, due to many professionalization efforts in many countries, physiotherapists increasingly assume their responsi bility as an equal partner in an interdisciplinary team. Within this professionalization process the physiotherapy-specific assessment procedures pro gressively play a unique role in interdisciplinary cooperation. However, in spite of this favourable professional development, .based on observations during supervi sions in daily clinical practice in various countries, it still cannot be emphasized enough that no physiother apeutic treatment should be carried out without
The employment of assessment procedures may be con sidered as a professional attitude of continuous critical appraisal. Herein the physiotherapist continuously assesses examination findings, evaluates treatment effects and above all reflects on the decisions and choices made. Additionally, the therapeutic relationship and the communication and educational processes are being assessed. With the use of continuous assessment procedures physiotherapists express their principal role in self-responsible 'problem solving of movement dys functions and enhancing movement' rather than solely performance of treatment measures as prescribed by another authority in the treatment team. At times it seems that some physiotherapists feel they would not be able to apply 'the Maitland Concept' if in certain clinical circumstances they would not be able to apply the art of passive mobilization techn iques or manipulations with some patients. If they nevertheless engage themselves in the process of con tinuous assessment and reflection they will always be employing one of the most essential aspects of this concept. thorough physiotherapy-specific examination.
Com munication In the process of continuous assessment communicat ion plays an essential role. Some communication strat egies are described in Chapter 3. Precise wording is essential. Furthermore, careful observation is import ant to pick up the subtleties of non-verbal commu nication as an expression of the individual illness experience or of the therapeutic relationship. In all phases of assessment, but certainly during reassess ment procedures, subtle communication may guide the patient to a different perception of the movement disorder. When the patient is guided towards self observation by gentle and precise communication strategies, it is in fact possible that the patient for the
first time experiences that beneficial changes in move ment functions occur, even if the pain seems lasting.
Balance between procedures and interactions: client centredness It has been shown that more experienced physiother apists, with their experience of pattern recognition and superior organization of their knowledge base, are more capable of interacting with the patient during treat ment procedures and develop a different kind of thera peutic relationship in which the technical procedures and social interactions with the patient are in balance (Jensen et al 1992, 1999). However, some qualitative research studies indicate that there may be a tendency for physiotherapists to let their procedures prevail in a first session, with a therapist-centred rather than a patient-centred agenda (Trede 2000). Additionally, more empathy towards the patients with their personal background appears to be shown in later sessions than in the first consultation (Thomson et a1 1997) and infor mation seeking with regard to the patients' personal experiences with their problem is more likely to happen in a second treatment session than in the first meeting (Sluys & Fennema 1989). Often this will be well received by patients; however, some patients require more 'sensitive practice' and may be 'lost' in a too pro cedural agenda if the setting has not been discussed beforehand (Schachter et al 1999) or if patients' per sonal or cultural beliefs have not been sufficiently respected (Edwards 2000). A beginner in the profession may feel overwhelmed with all the requirements to fulfil a more 'patient centred' agenda, as clinical experience seems to be an essential prerequisite to developing such an approach. There is some indication that experienced physiother apists have developed the interactive skills as a part of the intuitive, experiential knowledge base (Edwards 2000, Hengeveld 2000). While intuitive reasoning undoubtedly has its place within clinical practice under certain conditions, it has the disadvantage that it often contains the application of implicit knowledge. If not made explicit, beginners may not get sufficient sup port in clinical training to develop these implicit skills. Furthermore, it is possible that interactive skills have become so self-evident that they may not receive extra attention in the therapeutic process and are missing in the declarative knowledge of a profession. The following quote may serve as an example: 'Physiotherapists may give the impression that they do not recognize and publicly value the interpersonal and contextual aspects of their activities' (Bithell 1999). However, in order to allow a conscious development of these skills, it is important to find a healthy balance
91
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MA ITLAND'S PERIPHERAL MAN IPULATION
L during undergraduate training between the applica tion of more routine procedures and interactive rea soning skills. Recognition of some critical phases in the therapeutic process may aid in the development of a balanced approach between procedures and inter actions (see Fig. 3.3). It is important that the physio therapist not only seeks information, but also gives information to the patient at crucial moments.
• •
The World Confederation of Physical Therapists defines diagnOSiS within physiotherapy practice as follows:
Diagnosis arises from the examination and evaluation and represents the outcome of a process of clinical reasoning. This may be expressed in term of movement dysfunction or may encompass categories of impairments, functional Limitations, abiLities/ disabiLities or syndromes. wePT (1999, p. 7)
Interview style In order to gain relevant information with regard to physiotherapy diagnosis and treatment, as well as to simultaneously develop a therapeutic relationship, it is important to follow an interview style with half open questions rather than a fixed set of questions or a questionnaire. The procedures of history taking as described in Chapter 6 are in fact half-open questions in which the physiotherapist may seek clarification on information given and 'delve' further into a certain topic if it seems relevant. However, if these procedures of questioning are too rigidly applied, solely to find information on symptoms and signs with their conse quences, important information on patients' individ ual perspectives on their disorder and their capacity to cope with the disability may get lost (French 1988). Furthermore, if therapists rely solely on strict ques tions or even a questionnaire alone, many important cues such as facial expression, selection of words, into nation of voice - which are also very decisive in clinical decision making and the development of a therapeutic relationship - may be missed out. Therefore the physio therapist is encouraged to keep a certain flexibility in the application of the procedures of questioning and to integrate other forms of clinical reasoning (e.g. narra tive reasoning). This will enable the therapist to get an account of the patient's individual story rather than controlling the patient with strict assessment criteria in which the patient is allowed to talk only about those aspects that are relevant to physiotherapy diagnosis and treatment planning from the perspective of the physiotherapist (Thomson 1998). This process requires a high skill in interviewing and examination, which may be challenging for a novice in the field. It is recommended that the novice therapist initially follows an algorithm of set procedures, plan ning steps and certain communication strategies in crit ical phases of the therapeutic process (Chapter 6).
determination of treatment interventions define parameters to monitor the effects of all therapeutic interventions.
This description of physiotherapy diagnOSiS indicates that most of the diagnostics within physiotherapy fol Iow a movement paradigm; however, the findings of a physiotherapist may support pathobiological diagnos tics in the realm of medical practitioners as well. Furthermore, the description indicates that the inter ventions of physiotherapists are aimed at the enhance ment of movement functions. Passive mobilizations and manipulations frequently play a central role in this process and often may be considered as a 'kick-start' to normal active movement functions (Banks 2002).
Forms of assessment Various forms (and timings) of assessment have been described (Maitland 1987, 1991; Maitland et al 2001) and are summarized as follows: •
•
•
•
•
at initial consultation(s), including the welcoming and information phase reassessments in various phases of each treatment session assessment during the application of treatment interventions periodic retrospective assessments and prospective assessments to monitor the overall process final analytical assessment, including the parting phase in which measures are undertaken to enhance 'long-term compliance'.
These assessment forms need to be incorporated into critical phases of the therapeutic process, as described in Chapter 3.
Purposes of assessment Physiotherapy assessment serves several purposes: • •
physiotherapy diagnOSiS definition of therapy objectives
ASSESSMENT AT INITIAL EXAMINATION In the first treatment session(s) the physiotherapist has to sort out a complexity of information about the
Princi ples of assessment
patient and shape a treatment plan accordingly. This information includes the following cues: • • • •
•
•
biomedical psychological social cultural.
Often a considerable amount of improvisation is necessary to adapt the procedures to the special needs of the patient. However, and especially for novices in the field, it is essential to develop a clear, disciplined set of procedures of examination and planning. After some years of clinical experience, when these proce dures have become more natural, automatic skills, the experienced physiotherapist increasingly will be able to modify and adapt the basic procedures to the indi vidual needs of the patient.
Algorithm for first session(s}
This has been investigated with occupational therapists (Mattingly 199 1 ), but similar processes occur within physiotherapy as well (Hengeveld 1998, Edwards 2000, Jones & Rivett 2004) (Fig. 5.2).
Causes and contributing factors To achieve the above-mentioned objectives the physio therapist needs to have developed highly complex skills of clinical reasoning in which not only various forms of clinical reasoning but also various paradigms to medical practice are employed: •
When considering the causes of the patient's prob lem the physiotherapist follows a biomedical model of thinking in seeking information about pathobiolog ical processes. This is an essential element of assess ment, as it defines possible precautions and contraindications to physical examination and treat ment procedures; furthermore, it may support phys icians in biomedical diagnosis. If the physiotherapist suspects that the patient's disorder is not primarily a movement disorder, but a pathobiological process which requires further medical investigation, the patient should be referred back to the physician.
•
Another perspective which is frequently followed in the assessment of pain during movement is the employment of a neurophysiological model of pain mechanisms in which it is acknowledged that pain may exist due to processes in neuronal networks in the absence of pathobiological tissue processes. The research on pain and neurophysiological pain mech anisms provides physiotherapists with useful theoret ical frameworks for explanations of clinical practice.
•
As a most essential model for physiotherapy practice, the physiotherapist follows a biopsychosocial movement
The following algorithm of information, procedures, reflection and planning is suggested for a first session with a patient: • • •
•
•
Welcoming and information phase Subjective examination Summary and planning of the physical examination Physical examination, including first treatment and reassessment Summary of first session: - reflection/summarizing - hypotheses - planning of next session.
(These steps are described in detail in Chapter 6.)
Objectives of the first session(s) Within the first session(s) physiotherapists follow var ious objectives, searching for information regarding: • •
causes and contributing factors treatment goals and suitable interventions
active integration o f the patient i n the treatment process any precautions and contraindications as regards examination procedures or treatment interventions.
Causes
Treatment goals
Contributing factors
Selection of interventions
,
,.----.....-..,
/
CLINICAL JUDGEMENT
Contraindications? Precautions?
Active integration of the patient in the therapeutic process (Therapeutic relationship - communication)
Figure 5.2
Various objectives of
assessment in the initial phase of physiotherapy.
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paradigm i n which a physiotherapy-specific diagno sis of movement functions and disorders is defined, which serves as a basis for treatment planning. Within the different paradigms physiotherapists analyse various factors which may both cause and contribute to the patient's movement disorder. These hypotheses may include: • •
• • •
•
movement behaviour and habits impairments of various movement functions (e.g. joint movements, neurodynamics, muscle functions, soft tissues, etc.) activity levels, participation and lifestyle factors pathobiological processes cognitive, affective, sociocultural factors, earlier experience neurophysiological pain mechanisms.
The contributing factors may be one reason why the momentary nociceptive state or movement dysfunc tion developed in the first place or is maintained. In the Maitland Concept this was originally called 'the cause of the cause'; however, the term is somewhat awkward, as often a multitude of contributing factors may exist (see Reassessment below).
Treatment planning The causes and contributing factors should be taken into account when planning treatment, which opti mally takes place in a collaborative manner with the patient. However, it needs to be determined if certain interventions cannot be performed (yet), as precau tions and contraindications may be present. Treatment objectives regarding movement dysfunctions
Treatment objectives are probably best defined in terms of impairments/functions, activity and participation as described in the International Classification of Func tioning, Disability and Health (WHO 2001) (Chapter 4). Cognitive and affective goals Following the definition of the treatment objectives on the various levels of dis ablement and movement disorders, it is often relevant to define (and reassess) treatment goals on cognitive and emotional levels as well. Emotional factors, cogni tive aspects, beliefs and so on have been described as psychosocial risk factors (,yellow flags') to ongoing disability due to pain (Kendall et al 1997, Turk 1997, Linton 2000, VIae yen & Linton 2000). Physiotherapists increasingly acknowledge and follow up these factors in their therapies. . Fear - or better said, 'lack of trust' - of moving may be influenced directly by providing patients with the experience of the feared movements and activities
under the guidance of the physiotherapist (Muncey 1998). At times passive physiological movements may play an important role, which could be a first step towards active movement (Zusmann 1998). On a cognitive level, physiotherapists may pursue, for example, educational strategies with regard to the benefits of movement in spinal problems (Abenhaim et al 2000) or in degenerative osteoarthritic changes (Dieppe 1998). Furthermore, they may follow teaching strategies with regard to pain and neurophysiological pain mechanisms (Gifford 1998a, Butler & Moseley 2003), as the patient's own paradigms or belief systems may differ from those of the physiotherapist. It is pos sible that a patient believes that 'hurt equals harm' and therefore thinks that the disorder will be resolved by resting or by removing the structures at fault, whereas the physiotherapist follows the perspective of reduced activity rather than bed rest in acute nociceptive pain states with a gradual increase in the level of movement and activity as the healing process continues. If these viewpoints or individual paradigms have not been clarified, it may leave the patient confused and there fore pOSSibly impedes compliance with therapy and treatment outcomes. A recent study indicates the bene ficial effects of educational strategies on some physical examination tests (Moseley 2004). Selection of interventions
The selection of treatment procedures in the first session(s) takes place collabora tively with the patient, the physiotherapist offering var ious possibilities in which the agreed treatment goals may be achieved and reassessed. A balanced approach to the selection of treatment interventions is needed (McIndoe 1995), in which the phYSiotherapist has devel oped skills in various treatment methods. Currently the debate on the merits of 'hands-on' and 'hands-off' treat ment seems somewhat polarized, in which 'hands-on' treatment could be seen solely as a passive modality in which the patient becomes increasingly dependent on the hands of the physiotherapist. However, if passive movements are used judiciously in combination with self-management strategies, education and communi cation, manipulative physiotherapists have a lot to offer in the treatment of painful movement disorders and the secondary prevention of chronic disability due to pain.
Therapeutic relationship and active integration of the patient The therapeutic relationship has been described in Chapter 3. The first session starting with history taking follows various aims, including: •
information gathering with respect to physiotherapy diagnosis and treatment planning
Principles of assessment
•
the development of a therapeutic relationship (Casanova 2000).
Communication processes with regard to information gathering increasingly have become explicit proce dures and are well described (Maitland 1986). However, the interactions serving the therapeutic relationship and psychosocial assessment - with elements such as expectations, fears, emotions, beliefs and so on - usually take place impliCitly, often almost casually. Frequently these aspects of the therapeutic interactions do not receive much attention in under- and postgraduate physiotherapy education (Chin A Paw et al 1993, Wiegant 1993, Hayes et a11999) and seem to be taken as self-evident, not needing much further consideration. However, with regard to the definition of 'good physiotherapy practice', next to thorough professional skills, patients particularly appreciate those elements which determine a therapeutic relationship. Aspects such as empathy, friendliness, listening skills, having the impression that questions can be asked, explan ations, trust and the capacity to motivate people, etc. (de Haan et a11995, Kerssens et a11995, Sim 1996, May 2001) may in fact influence the active integration of the patient in the therapeutic process (Mattingly 1991, Klaber Moffet & Richardson 1997) and enhance com pliance to the recommendations and self-management strategies as suggested by the physiotherapist (Sluys 2000); for more details, see Chapter 3.
Precautions and contraindications In a first session in which initial decisions will be made regarding treatment goals and the selection of thera peutic interventions, it is essential to consider pre cautions and contraindications to the physiotherapy interventions. Clinicians may diagnose according to their thera peutic possibilities and blend out other causes and treatment possibilities for which different specialists in a team need to be consulted. This may be one of the major errors in the reasoning processes of clinicians, in which certain hypotheses are being favoured above less preferable hypotheses (Grant et al 1988). A sur geon, for example, may pOSitively search for a lesion to be operated upon and overlook possibilities of move ment therapy, or in a psychiatriC unit the patient may be screened for a psychiatric disorder while the pos sibility of an acute pathobiological process is ignored. Physiotherapists may have a tendency to search positively for movement dysfunctions and blend out pathobiological causes, which require the attention of a medical practitioner. Various publications repeatedly publish reports of patients seemingly presenting with movement disorders when in fact serious pathobiology
was present (Boissonnault 1995, Refshauge & Gass 1995, Wells 2004). However, the opposite has also been reported when a patient was treated for visceral problems, whereas the symptoms derived from a movement disorder (Grieve 1986). In atypical presen tations of symptoms it is important that the physio therapist is alert to serious pathobiological processes and refers the patient to the appropriate specialist if needed. Direct-contoct practitioners For many years it has been considered the specific responsibility of a physiothera pist to assess precautions and contraindications to examination and treatment procedures (Maitland 1968). However, since phYSiotherapists increaSingly assume the status of a 'direct-contact practitioner', responSibility and accountability increase with regard to possible contraindications or situations which addi tionally need the care of another specialist in the treat ment team. Physiotherapists need to develop a network of other specialists to whom a patient may be referred if this is deemed necessary.
Contraindication or precaution? In basic textbooks of physiotherapy the topic of contraindications at times seems somewhat clouded, as frequently it is stated that tumours, inflammatory processes, metabolic diseases and fresh fractures would be considered a contraindi cation to physiotherapy interventions. However, almost every physiotherapist will remember the treat ment of a patient presenting with such a biomedical diagnosis. These medical conditions may define cer tain precautions to particular physiotherapy interven tions; however, in themselves they may not necessarily be a contraindication. At times temporary contraindications to examin ation procedures and treatment exist, if specific bio medical information is missing. A patient may, for example, present with severe pain in the upper arm after a fall from a bicycle a couple of days ago. At inspection the patient shows haematoma in the upper arm and active movements of the glenohumeral joint are painful and restricted in most directions. The physi otherapist suspects a fracture and refers the patient back to the clinician. Medical examination reveals a stable fissure of the major tubercle of the humerus and 10 days later the patient is referred back to the physio therapist. The contraindication of the first session is now in fact an indication for movement therapy, while respecting the necessary precautions regarding the healing phases of the fracture. Rather than the above-mentioned pathobiological conditions, frequently it may be more helpful in the assessment of patients with low back pain to identify
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any risk factors for serious disease ('red flags')l which should aid the clinician in making decisions regarding further medical investigation or referral to other clin icians (CSAG 1994, Kendall et a11997, Waddell 2004): •
• • • • • • •
• • • • •
features of cauda equina syndrome (especially urinary retention, bilateral neurological symptoms and signs, saddle anaesthesia, loss of anal sphincter tone or faecal incontinence) significant trauma systematically unwell, weight loss history of cancer fever intravenous drug use steroid use patient 50 years, presenting with a first episode of pain severe, unremitting nighttime pain pain that gets worse, once lying down marked morning stiffness ESR >25 X-ray: vertebral collapse or bone destruction.
When indicated, various body systems should be screened in the first physiotherapy consultation in order to identify pathological processes which require the attention and diagnosis of another specialist. The following screening is suggested: • • • • • • • • • • •
cardiovascular system pulmonary system gastrointestinal system urogenital system endocrine system nervous system pathological origins of head and facial pain musculoskeletal system disease rheumatic disease psychiatric disorders skin disorders.
For detailed reading, consult Boissonnault (1995) and Goodman & Snyder (2000). In general, information from the basic examin ation procedures of the manipulative physiotherapist (Chapter 6) may highlight situations in which patients
need referral to an appropriate medical practitioner (Refshauge & Gass 1995): • •
• • •
•
•
• •
Precautions In the absence of contraindications, cer tain precautions may need to be respected in examin ation or treatment procedures. Physical examination In the planning phases of physi cal examination and treatment precautions must be considered in order to determine the extent of physical examination that can be undertaken safely. In this regard, physical examination is not necessarily a fixed set of standard procedures. The precautions (and contraindications) are mostly determined by hypotheses with regard to pathobiolog ical processes and neurophysiological pain mechanisms. In dominant nociceptive or peripheral neurogenic mechanisms the constructs of 'severity and irritability' of pain and 'nature' factors serve in the decision making process regarding dosage (extent) of physical examination and initial treatment (see 'Planning of the physical examination', Chapter 6). Precautions in relation to physical examination pro cedures may be determined by: • •
1
Reference has been made to so-called 'orange flags', which are indicative of psychiatric disorders for which patients should also be referred to appropriate practitioners. This may be an essential distinction from biopsychosocial risk factors ('yellow flags') to long-term disability due to pain, which are not necessarily indicators of any psychosocial problem or psycho pathological process (Main 2004).
any severe unremitting pain any severe unremitting pain that stays the same or worsens despite rest, analgesia or appropriate intervention severe pain with little disturbance of movement severe night pain worsening neurolOgical deficit despite appropriate intervention non-mechanical behaviour (e.g. excellent response to anti-inflammatory medication, little movement disturbance, lack of response to analgesia, unusual pain patterns, inability to ease symptoms by positioning or postures or movement, heat or other modalities, long-lasting morning stiffness) severe pain without major trauma (or severe undiagnosed pain following major trauma) or a relatively minor incident in history leading to severe pain and disability severe muscle reactions ('spasm') marked trauma prior to the current symptoms.
•
• • •
the irritability of the disorder the severity of the disorder pathobiological processes - tissue mechanisms, stages of tissue healing, dominant neurophysiological pain mechanisms the stage and stability of the disorder (history) the patient's general health the patient's movement behaviour, perspectives and expectations.
Principles of assessment
Precautions in treatment planning During treatment plan ning and before the application of each intervention, it is essential for the physiotherapist to consider: 'Which objectives do I want to achieve with this intervention but what should not happen?' This clinical question is often answered implicitly by more experienced phys iotherapists; however, for novices in the field it is essential that they consider these questions explicitly before the application of any treatment intervention (mobilization, electrotherapeutic modality, exercises, information strategies, etc.). The consideration of precautions during the applica tion of therapeutic interventions is an important element of 'assessment during the treatment' in which the physiotherapist regularly checks whether treatment goals are being achieved and that no undesired side effects occur (see Assessment during treatment below). •
•
During treatment the therapist should be carefully monitoring inflammatory signs and nerve con duction by the regular evaluation of reflexes, sen sation and muscle strength, as well as the occurrence of pain, if the objective of treatment is to move within pain-free limits. The therapist should also monitor a fracture site if movement is already tak ing place but the fracture is not yet 100% stable. Reassessment of cognitive information to monitor if the information given to the patient was clear and did not increase any confusion. The patient may repeat in his own words how he understood the information; it is essential to give the patient time to ask questions and to refer back to the infor mation ('I gave you a lot of information last time, but I'm not sure if it was a bit too much. Do you have any questions regarding this?').
an ultimate source of information in the diagnostiC process. Therefore the process of information gathering with regard to physiotherapy diagnostics may stretch out over the first two or three treatment sessions before most hypotheses are clarified and a more definitive course of treatment is outlined (see Fig. 5.1). REASSESSMENT As pointed out at the beginning of this chapter, the effects of the various interventions are continuously monitored and the treatment is adapted to the actual situation of the patient as required. Reassessment proce dures play a fundamental role in this process. Reassess ment has always been an important aspect of the Maitland Concept of physiotherapy. As a process it was first described in 1968 (Maitland 1968) and nowadays it has become a part of the declarative knowledge of the profession (WCPT 1999). Reassessment procedures should take place during each treatment session: •
during the initial physical examination phase in the first encounter between physiotherapist and patient, after the examination of various active and passive movement tests
•
at the beginning of each subsequent treatment ses sion: pretreatment assessment, to reflect on the reac tions to the last treatment session and the time before the patient came to therapy
•
immediately after the application of the various treatment interventions - proving the value of the interventions; this includes interventions such as information and education
•
at the end of the treatment session.
Summary: purpose of initial assessment
Reassessment procedures have different purposes:
On the one hand, the first session(s) serve to gather information with regard to causes, contributing fac tors, precautions and contraindications, and treatment planning, and on the other hand to develop a thera peutic relationship. During this process the physiotherapist develops multiple competing hypotheses concerning sources of movement disorders, pathobiological processes, pre cautions and contraindications, contributing factors, individual illness experience, levels of disablement, management and prognosis. These hypotheses may be confirmed, modified or rejected depending on the results of the examinations and the reactions to the first treatment interventions. If treatment interventions are accompanied by thor ough reassessment procedures, treatment itself becomes
•
They allow the physiotherapist to compare treat ment results, hence proving the value of the selected interventions.
•
Reassessment after treatment aids differential diag nosis. Not only examination findings but also reac tions to treatment interventions (particularly with passive movements) make a contribution to differ ential diagnosis of the sources of the movement dysfunctions.
•
Reassessment enables the physiotherapist to reflect on the decisions made during the diagnostic and therapeutic processes. Through regular reassessment procedures hypotheses with regard to sources, con tributing factors and management strategies may be confirmed, modified or rejected. Via the consequent
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[ application of reassessment procedures the physio therapist learns to recognize patterns of clinical pre sentations, with more or less successful reactions to the intervention selected. For these reasons reassess ment procedures support the development of the individual, experiential knowledge base of the physiotherapist. •
•
Regular reassessment procedures additionally sup port the learning processes of the patient. From a cognitive-behavioural therapy perspective, reassess ment procedures may assist the patient in develop ing the perception that beneficial changes occur, even if the pain as a sensation seems lasting. It is during the reassessment that patients may actually experience changes in a state in which they did not expect any differences to occur. With the combination of careful communication strategies and a good awareness of the possible changes in subjective and physical examination parameters ('asterisks'), reassessment procedures may be considered as one of the crucial aspects of the therapeutic process.
Box
-
5.1
Indicators of change------"1
Subjective examination •
Pain : sensory aspects such as intensity, quality, d u ration, localization, frequency
•
Level of activity a n d participation normalizes
•
Trust t o use body again i n daily life functions
•
Decrease in the use of medication
•
I n creased u n derstanding
(WHO 200 1 )
•
Em ployment of diverse coping strategies if the pain or discomfort fla res up again
Physical examination pa rameters •
I nspection para meter (e.g. anta lgic posture)
•
Active tests: range of motion, quality of movement, sym ptom response
•
Passive tests: cha nge in the behavio u r of pain, sense of resistance and motor responses ( 'spasm')
•
Iso metric m uscle testing: changes in strength, quality of contraction and symptom response
•
Palpation fin d i ngs: quality and symptom response
•
Neurological conduction testing: cha nges i n quantity a n d q u a l i ty o f responses
Indicators of change In the application of reassessment procedures physio therapists need to have a clear picture in mind as to how the symptoms and signs may change as a result of the interventions (Box S.l). 1t is possible that the patient initially may perceive the condition as unchanged, not having learned yet which small changes may be considered as a positive development. If the reassessment in such a case is only superficial, the thera pist may react too quickly with a different approach to treatment. However, if the therapist more profoundly assesses the details of the various symptoms and signs and educates the patient to observe accordingly, both the physiotherapist and the patient may learn that the previ ous treatment in fact has made a beneficial change in the patient's movement disorder and the selected approach to therapy needs to be continued.
Treatment intensity •
For exa m ple, passive movement, active exercises, soft tissue tec h n iques, higher dosage possible without provoking d i scomfort
Behavioural parameters •
For exam ple, facial expression, non-verbal la nguage, eye contact, use of key words a n d phrases, a utomatic movements s u c h as habitual i n tegration of arm with d a i l y life functions, etc.
" I n the g u idance of a state of 'individual i l l ness experience' towards a state of individual health experience, many detailed changes may indicate a positive progression, even if the patient initia l ly may perceive the condition as unchanged.
In order to be able to perform fruitful reassessment procedures in which both patient and phYSiotherapist learn about possible favourable changes after an inter vention, the quality of communication and the choice of words are essential.
'How did it feel this morning when you got out of bed compared with how it used to feel?' The start should be in more general terms, allowing the patient to provide information that seems important. This information may be more valuable because of its spontaneous nature. After this spontaneous phase at the beginning of a session, the physiotherapist may deliberately seek to reassess the level of activity, the incidence and qual ity of pain and the integration of newly learned coping strategies.
Subjective reassessment
Convert statements offact into comparisons
At the beginning of a session it is important to seek spon taneous comments. It is not helpful to ask immediately,
It is essential in the reassessment process to convert state ments of fact into comparisons to previous statements.
Quality of communication during reassessment procedures
Principles of assessment
99
] The comparisons should be recorded in the patient's case notes. It is essential that physiotherapists recognize the statements of fact which are regularly given by patients and to convert them directly into comparisons. For example, a patient may initially answer to the question 'How have you been? ' with 'The same', suggesting that the therapy may not have helped at all yet. However, further questioning may indicate that favourable changes have indeed occurred: Q 'The same? What bothered you especialiy?' A 'Last night during the football game on television, I started to feel my leg again.' Q 'About what time was that?' A 'Towards the end of the game.' Q 'Did your leg recuperate?' A 'I got up and I did this shaking with my leg, as you showed me to do, and then it disappeared quickly.' Q 'Could you compare this with the last time you watched a football game on television? ' A 'Oh, well that was 3 weeks ago, then I could not sit at ali, I had to lie down.' Q 'How did it differ last night?' A 'Well, I could sit much longer and that exercise really helped to get the pain down again.' Another way to achieve a better comparison may be the question, 'If you compare with 3 weeks ago, when you came for therapy for the first time, do you think you would have been able to watch a football game?', to which the answer may well be, 'Oh no, 1 could not sit at all, now it is much better.' In order to develop a useful reassessment, state ments of fact have to be converted into comparisons to previous statements.
Some relevant communication techniques in reassessment procedures There are some important communication techniques to attain this form of subjective reassessment: •
Immediate-response questions - sometimes a patient's statement needs an immediate-response question in order to receive clear information with regard to comparisons. In response to the question, 'How have you been? ', the patient may say, 'I'm feeling better.' This answer demands an immediate ques tion, sometimes even before the patient has time to take breath or say anything else, for example 'Better than what? ' or, 'Better than when?' It is possible that the patient was worse immediately after treatment and has improved now to the state he was in before the last treatment, thus no further improvement may have occurred, although the
initial statement of the patient may tempt the physiotherapist to think so. •
Key words and phrases - Having asked the question, 'How have you been?', the patient may respond in a general and rather uninformative way. However, during subsequent statements the patient may include, for example, the word 'Monday'. This may mean something to the patient and therefore it is often effective to use it and ask, 'What was it about Monday?', or 'What happened on Monday? '
•
Paralleling - Often it is helpful to follow the patient's line of thought and to adapt the questions appropri ately. However, it is essential for the physiothera pist to keep clearly in mind which information is being sought and not to be so confused by the patient's line of thought that the 'information seek ing' is forgotten.
Collaborative goal setting and parameter definition In addition to defining treatment objectives in a collab orative way (Mead 2000) as suggested in Chapter 3, frequently it is also useful to decide on which param eters to use to measure progress of these objectives in a participative manner. The following communication example may underline this principle: Q 'I would like to summarize: we agreed that we would work together on your pain in your neck and shoul der, which occur especially when you are painting for a longer period and when you work at your personal computer for a longer period of time. Am I correct with this summary?' A 'Oh, well, yes.' Q 'Or did 1 miss out on something? Are there other times when you feel restricted because of this problem?' A 'I also have problems when 1 read in bed and some times 1 cannot sleep because of the pain.' Q 'Oh yes, I'm sorry that I did not mention that in the summary. Now we also need to measure the progress. We won't be able to have the situation going from 'bad today' to 'good tomorrow'. How would you be able to find out by yourself at home if things may be changing?' A 'Well, I wouldn't know.' Q 'Sometimes people report that they will be able to perform activities longer, the pain may be less intense or the area of symptoms may become smaller. Or you may recuperate quicker after the activity, especially if you try the exercise that we did just now. Which activity is it most important for you to improve the soonest, if possible?' A 'Painting and writing at the PC'
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L Q 'How long are you able t o perform these activities?' A 'Well, about an hour and then I stop because it hurts too much.' Q 'Would you like to be able to do these things for longer?' A 'Oh sure. Before I got this shoulder problem, I could paint for hours.' Q 'Would you be able to monitor until our next session how long you feel able to paint or write, and, at any time you feel less comfortable with your arm, to do the exercise and see if you feel capable of painting or writing any longer?' A 'Oh sure, I'll do that.' Q 'Then I will look from my perspective at the test movements in sitting that we performed together today. However, it would be great if you could remember how they felt today. I need your informa tion on these tests as well.'
Balance in reassessment in subjective and physical parameters It is vital to have a clear picture of the patient's main problem, including where and when the pain occurs, how daily life functions may be limited and how the patient is able to cope with the situation. In addition, the objectives of treatment should be clarified, which may on the one hand be control of pain and on the other the improvement of the limited activities and restriction of participation aspects. Too often in later treatment sessions both the patient and the physio therapist have the impression that nothing seems to change for the better only because this information has not been specified in sufficient detail in the initial ses sion. With sufficiently detailed information a better comparison of all the relevant parameters is possible, and more precise statements can be made regarding which aspects in the patient's situation are changing and which elements remain unaltered. A balanced approach to the reassessment of sub jective and physical parameters is necessary. Some physiotherapists rely solely on the observation of phys ical examination findings and only employ tests with an acceptable inter- and intra-tester reliability. How ever, it is argued that clinicians should retain a certain degree of scepticism if tests with a high reliability coefficient are directly claimed to be clinically useful as well (Keating & Matyas 1998, Bruton et al 2000) and vice versa: tests with a low correlation coefficient (e.g. some palpation tests) therefore would not be use ful clinically. Often the combination of tests of both sub jective and movement parameters, as well as pain in combination with resistance, may provide the clinician with valid reassessment parameters (MacDermid et al
1999). Leaving out subjective parameters carries the inherent danger that the therapeutic process becomes a rather mechanical process, in which not much space is left for the individual perceptions of the patient with regard to the disorder. In fact it is increasingly recommended, both in clinical work and research, that the patient's perspectives be integrated (Borkan et al 1998).
Measurable changes Before a patient subjectively feels more free both in daily life activities and pain levels, or before the physio therapist can reliably measure changes in range of motion, subtle changes in inspection or palpation find ings may be the first indicators of positive changes in the patient's condition. In certain conditions, such as acute radicular pain states where it can be expected that occurrence of clear measurable changes may take place in 10-14 days, patience both from the patient and the physiotherapist is required. In the case of possible radicular changes the physiotherapist will also need to employ regularly those tests that are indicative of pos sible negative changes with regard to precautions and contraindications (e.g. regular performance of neuro logical conductivity examination tests).
Behavioural parameters In certain conditions, frequently in the need of a more multidimensional approach to treatment, the physio therapist may not always be able to directly observe changes in, for example, mobility or pain reaction. In such cases it may be useful to use behavioural param eters as an indicator of change in the patient's condi tion, indicative of the individual illness experience. The following examples serve to highlight this point: •
In patients with complex regional pain syndromes (CRPS I) protection and guarding of the extremity may frequently be observed (Merskey & Bogduk 1994). After some sessions it may be an indicator of improvement in the patient's condition if the move ments of the arm become more and more a part of the unconscious body language and the hand is more habitually used again (e.g. in fastening a shirt).
•
The facial expression, smiles, eye contact, selection of words and even the detail in which an incident or a history of a disorder is described may also be indicative of a change in the individual illness expe rience. As an example, it is possible that a patient uses less frequently emotionally laden words such as 'It's all so terrible', answers less often with
Principles of assessment
'Yes . . . but', smiles more frequently, at times may make a joke, has more eye contact or becomes more aware of other people in the environment, and so on.
Change within the first
24
hours after treatment
There are specific times after treatment when changes in the patient's symptoms and signs can indicate the effect of treatment: •
• •
immediately after treatment and up to about 4 hours after treatment the evening of the treatment on rising the next morning.
The question can be asked, 'How did you feel when you walked out of here last time compared with when you walked in?' A patient may feel much improved immediately after treatment; however, it may not have lasted longer than an hour. This may indicate that the physiotherapist should continue with a similar treat ment and see if the improvement lasts for any longer, especially if treatment with passive mobilization is sup ported with self-management strategies. If the improve ment is only of short duration and the patient's symptoms and signs quickly fall back to the same level as in the initial assessment, it is possible that additional sources need attention (e.g. movement dysfunctions in the neck or neurodynamic system in combination with the symptoms and signs of a tennis elbow). If the patient feels exacerbation of symptoms after treatment, it is essential to find out how the patient felt on leaving the treatment room and how the symptoms developed afterwards. If symptoms were increased for about 4 hours, and during the evening the symptoms were reduced to even less than before the treatment, then the reaction may be considered as a favourable response. Rising from bed the following morning may also be indicative of favourable changes if the patient feels able to rise more quickly than usual and the stiff ness was less intense or did not last as long as usual. Having more difficulty rising from bed the morning after treatment may be indicative of a less favourable response to treatment, which may be the case in move ment dysfunctions with an inflammatory component. However, this needs clear consideration since, if a patient has been able to sleep for several hours during the night for the first time in many weeks, then it is a favourable response to treatment and in this case any morning stiffness does not need to be of too much con cern to the physiotherapist. Patients may report soreness following a previous treatment session. This must always be clarified. Is it the disorder that has become sore, or is it just soreness
from the manual handling of the treatment technique? ('Is it a surface bruised feeling from my hand, or is it 'the thing' that you have got wrong which is sore?') On those occasions when it is determined that a patient's symptoms have been aggravated by the previous treatment, it is not always that the wrong technique was used - it may be that it was performed too strongly, with too much movement, for too long, or in the wrong position. Therefore, an effort must be made to see if the patient is aware of what it was about the technique that caused the soreness. This is particularly relevant if previous uses of the technique had been producing favourable progress so far.
The 'art' of reassessment Reassessment may be considered as an 'art' in many therapeu tic interventions.
Which interventions influence which parameters? It is important that the physiotherapist develops a clear image as to which interventions have an effect on the patient's condition. It is possible that some inter ventions may influence some active movement param eters and activities of the patient, whereas other interventions influence other tests and activities.
Follow multiple parameters in reassessment procedures At times physiotherapists claim to perform regular reassessments by performing only one physical examination test at the end of a whole session with various interventions. However, if reassessment is performed in such a manner, the physiotherapist will not learn which interventions are more beneficial than others for the patient's condition. Furthermore, the physiotherapist may come to the wrong conclusion that nothing in the patient's condition has changed, only because the incorrect reassessment parameter was being used.
Profound reassessment Others claim to re-evaluate the patient's condition by giving out a questionnaire or asking at irregular times 'How are you [the patient] doing?' or they randomly measure the mobility of a joint movement. However, all these forms of so-called reassessment are too superficial to gain a clear, detailed picture of the progress of the patient's condition and how the thera peutic interventions are influencing this process.
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L A balanced approach to reassessment and therapeutic interventions It is essential to have a balanced approach between the application of therapeutic interventions and their reassessments. It is imperative that the physiotherapist knows which interventions are more and which are less beneficial. Mostly the physiotherapist will need to reassess the general wellbeing of the patient and three to four movements after the application of a treatment intervention. However, at times of high irritability of a problem the physiotherapist may only reassess the current level of the pain ('present pain'), reassess the neurological conduction tests immediately after the intervention and test in more detail at the beginning of the next session. In the treatment of an elderly patient who has diffi culty in moving with any agility, it is possible that the physiotherapist may decide to let the patient continue to lie supine while reassessing the possible improve ments during the session and only at the beginning and towards the end of the session to test the patient's movements in sitting or standing.
Q A
Q A
Q
A
Q
Reassessment of cognitive objectives It has been stated that in physiotherapy much infor mation is given (Kok & Bouter 1990) but the quality of this information may need improvement (Van der Linden 1987, Sluys 2000) in order to enhance compli ance to the suggestions of self-management (Sluys 2000). For example, manipulative physiotherapists may use educational strategies with regard to the benefits of movement in pain states, in osteoarthritis or with disc lesions as well as to current insights on neurophy Siological pain mechanisms. The information given may be confusing or too complicated for the patient or may be in conflict with the patient's belief system. Reassessment of the cognitive interventions may be one step forward to improve the quality of information and education. •
After the physiotherapist has given some informa tion, it is worthwhile asking the patient to repeat in their own words what has been understood from the information: Q 'I have given you a lot of information - however I'm not sure if I've done a good job and that every thing is clear to you. Would you mind repeating in your own words how you've understood what I've told you?' •
In a back school, a patient may have just been given the information that it would be more useful to
A
Q
keep the back straight. However, the physiotherapist is aware that in certain circumstances the patient may not be able to comply with this due to job requirements and that other problem-solving strat egies will be required: 'I have given you a lot of information - how do you feel about this?' 'Oh well, I'll just have to do it if I want to keep my back healthy.' 'Isn't it going to be difficult to keep your back straight when you are working again as a car mechanic?' 'I've been thinking about this. As I told you, you should come and look at my job. It is hard at times. However, I will try.' 'I see. Well it's wonderful that you are so motivated. However, I know that there are situations in which it is just not possible to keep your back straight - for example if I came to you with a problem with the engine in my car, you would need to bend over the engine. Can you see any way to bend over the engine and still keep your back protected?' 'Well, I could put one leg up, or lean with both my knees against the frame.' 'These are very good strategies. What do you think you would do, if your back starts to hurt in spite of these plans?' 'Well, I could do this straightening of my back a few times as you've shown me so far.' 'Would you agree to me setting up this type of situ ation to see if we can practise these things as well as talking about them?'
After having given a lot of information, especially if it seems to be in conflict with the patient's current belief system, it is often very useful to give the patient time to reflect on the information given, and to return in, say, half an hour and give the patient time to ask any questions or to bring up any doubts. Alternatively, it may be helpful to ask the patient to think about things and write down any questions, and in the next session to discuss any situations which may have been unclear, confusing or even unacceptable. It is impor tant in such a case to truly take time for this discussion.
Cognitive-behavioural perspective to reassessment procedures Over the last decade an increasing number of publica tions have advocated that physiotherapists develop a cognitive-behavioural perspective to their work (Harding & Williams 1995, Klaber Moffet & Richardson 1997, Simmonds et al 2000). Cognitive-behavioural approaches aim to address any cognitive, emotional and behavioural responses to pain and disability.
Princi ples of assessment
Within physiotherapy practice a cognitive behavioural approach is a very subtle process in which the physiotherapist endeavours to be aware of the effects of all the interventions (including communication) on the thoughts, feelings and beliefs of the patient.
Therapy as a learning pracess Therapy may be considered as a learning process for the patient (and physiotherapist) in which the patient may go through a change with regard to ways of think ing, feeling or acting. Careful, comprehensive reassess ment procedures may be of particular value in guiding a patient in this learning process.
Guide patients in their experience In treatment it is suggested guiding patients towards their own experiences of activities rather than telling them what to do (Muncey 1998). In reassessment pro cedures a similar perspective is also necessary: guide the patient towards experiencing changes rather than telling them what the physiotherapist has observed. In this way reassessment may be considered as one of the most essential phases in the therapeutic process. It is a prerequisite that the patient is actively integrated into the process and that the physiotherapist explains the procedures and the patient's role in this process. A more superficial subjective reassessment - where the patient is only briefly asked to report on the pain, and further questions with regard to functioning and coping strategies are omitted - may contribute to feelings of hopelessness and helplessness in the patient. A patient may finish the treatment with the belief that physiother apy has not helped, although in fact some favourable changes have occurred, but neither the patient nor the physiotherapist has become aware of them.
Reassessment of physical examination tests It is crucial not only to perform test manoeuvres from the perspective of the physiotherapist but also to allow the patient to give an account of their wellbeing after the intervention and their own perspective on their capacity to move. It is essential that the patient recognizes the reassess ment procedures during the treatment session as such and does not misinterpret them as one of the many exercises to be performed; it is therefore important to announce it as another step in the programme of the treatment session. Furthermore, patients need to be educated to recog nize their own perception of all relevant parameters.
Patients need to be encouraged to observe not only their pain but also changes in range, freedom and trust to move the limb again in comparison with before the intervention. Frequently, patients are allowed only a passive role in which they can give information on changes in pain, but questions are omitted on how they themselves perceive the quality and range of the test movement. After that, often a reinforcement by the phYSiother apist is useful in order to teach the patient more about the physiotherapy-specific movement paradigms. Especially in the beginning of treatment it is essential that the phYSiotherapist gently educates the patient on those elements of a movement test that are relevant for the interpretation of reassessment.
(ET, Examiner's thoughts; Q, question; A, answer) Q 'Mr X, now that I have moved your arm for a while as a treatment, I would like to compare how you are now to how you were before. Could you please stand up again?' (patient stands up) Q 'How do you feel now in comparison with 10 min utes ago, before 1 did these mobilizations?' A 'I think just about the same, it does not hurt.' ET These remarks are more statements of facts than comparisons; however, as it is the first treatment, I would like to ensure that he does not feel worse gen erally; during the test movements 1 will compare in more detail. Q 'Is there anything that you feel may be worse than before?' A 'Oh no, certainly not.' Q '1 would like to look at some of your movements again - do you remember the ones we looked at, before 1 started treatment?' A 'I lifted my arm, didn't I?' Q 'That's right, and also you put your arm behind your back. Could you first lift your arm now and tell me what your impression is - how is it in comparison with before?' A 'It still hurts - here.' Q 'How do you feel this in comparison with before?' A 'Well, just about the same.' ET Previously he indicated much more in his whole upper arm, and now he indicates more locally around the shoulder. Although that could be an indication of improvement, I feel that Mr X does not necessarily perceive it as such, because it still hurts. Q 'Now you show me that you feel it mostly here (touches the patient in shoulder area) - do you remem ber where you felt it before?' A 'No, not really.' Q 'I remember you showed me more in your upper arm before; if that is the case, then it might be a sign
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[
ET
Q
A
Q Q
of improvement. Next time we should both look a bit more closely.' I had the impression his range of motion was also improved; I wonder if he perceives that as well. However, I do not want to be too suggestive in my questions, but I would like Mr X to learn that the parameters of range and quality of move ment are also of relevance in the interpretation of improvement. 'You've told me about the pain but I am also inter ested in how you feel about the way you move - do you have any impression of your arm moving differ ently, with more ease, or further up, or the other way round - maybe more difficult or not so high up?' (performs the movement again) 'No, I think I move a bit more freely - and don't you think I can move higher up?' 'Yes, that was my impression as well. I would like to measure this again.' (patient complies) 'What I've learned from this reassessment is that your arm seems to react well on the movements I performed on your shoulder. It tells me that your body needs to be moved, on the one hand by me, but I would like to show you a few movements which you can perform by yourself, particularly if you start to feel uncomfortable again. What do you think about that?'
Before performing reassessment procedures during the treatment session it is essential to: • •
announce it guide the patient's perceptions and divert statements of fact into comparisons
•
reinforce the effect by explanation ('What I've learned from this . . . ').
A balanced approach to reassessment of pain and function and activity - use of metaphors It has been suggested that, in reassessment proce dures, the physiotherapist should focus more on what the patient has been able to do rather than asking solely how much it had hurt (WaddeU 1998), otherwise the phYSiotherapist may inadvertently reinforce mal adaptive pain behaviour. This is an essential point. The approach must necessarily balance the reassessment of pain with an evaluation of function and coping strategies. Many phYSiotherapists seem to recognize this point from their years of clinical experience as they some times state that they rather avoid talking about pain, preferring to ask what the patient can or cannot do (Hengeveld 2000). With this aspect they shift attention
from the symptom 'pain' to the symptom 'activity and function' and to coping strategies. Metaphors Some physiotherapists may try to find an agreement with the patient not to talk about pain any more (Hengeveld 2000); however, this would deny the patient the individual experience of pain and suffering for which the help of the physiotherapist is sought. However, rather than avoid talking about pain, it is often useful to use metaphors in reassessment proce dures and still be able to acknowledge the experience of the patients with regard to pain and wellbeing. Instead of asking, 'How is your pain now in comparison with before?', it could be asked, for example, 'What does your body tell you now compared with before?' Some people give their own metaphors for their experience during the subjective examination which can be used during physical examination procedures; some may use colours or weather states. Others may find agreement with, for example:
Q 'If the pain is like a big wave on the ocean, would you only be satisfied if the ocean was fully calm without any ripple?' A 'Oh no, I can certainly accept some pain. It just should not get worse than it is now.'
In reassessment this could be used, for example: Q 'How is the wave now compared with before? Still on high storm?' A 'No, it seems a bit less.' Functional demonstrations i n physical examination If a patient seems overly focussed on the pain sensation, it is often useful to integrate more 'functional demon strations' (e.g. the tennis service) or working activity into the reassessments as these are frequently more meaningful to the patient than other physical exami nation tests such as SLR or hip flexion in supine posi tion. Furthermore, it is essential that, during the movement, the patient learns to observe parameters other than pain alone as a sensation (see ·above).
Conclusion: reassessment Reassessment procedures are an integral part of the physiotherapy process. A balanced approach to the comparison of subjective and physical parameters ('asterisks') is needed in which communication and a cognitive-behavioural approach play essential roles. Comparison of parameters will only be achieved if the starting point is clear: if it is not sufficiently clear from the first assessment which daily life functions are
Principles of assessment
limited due to pain or other reasons, no good com parison will be possible in later sessions. This may often leave the patient and physiotherapist in doubt as to whether the therapy has really served its pur pose. Furthermore, the definition of clear treatment objectives is impeded and neither patient nor physio therapist is capable of observing in sufficient detail if something is changing beneficially in the patient's situation. Although some will say this is too time consuming to be of value, successful treatment compels this degree of accuracy. It is essential if the physiotherapist is to remain in control of the treatment situation collabora tively with the patient. Given practice and experience, it is not a lengthy procedure.
•
increase of pain (particularly in cases of acute noci ceptive or peripheral neurogenic pain states)
•
neural conductivity (monitoring reflexes, muscle function and sensation regularly)
•
healing processes in soft tissues or bones (in relation to the phases of physiological healing processes)
•
autonomic reactions (e.g. during palpation of the spine)
•
general tension with increased muscle guarding and breathing patterns in those patients whose contribut ing factors to the problem may be lack of relaxation (this may be particularly relevant in the treatment of the thoracic spine or shoulder dysfunctions)
•
self-efficacy beliefs! externalization of locus of control! development of passive coping strategies (e.g. attributing the effects of treatment only to the hands of the therapist, but no application of self management strategies)
•
fear to move behaviour)
•
confusion (e.g. too much information without evaluating how the patient has understood the information).
ASSESSMENT DU R ING TREATMENT Another form of assessment is the evaluation during the application of treatment interventions. The follow ing aspects are monitored during the treatment: • •
Are the treatment objectives being achieved? Are there any undesired side-effects, as defined by the precautions in the planning phase of the session?
During the application of passive movement techniques changes in pain or resistance behaviour are evaluated. As long as these changes are favourable, the technique may be continued. When the changes cease to take place, it is often useful to perform a reassessment pro cedure to evaluate the direct effect of the technique as applied to the patient's condition. The duration of a passive movement technique will normally be decided by the reaction during the intervention.
Assessment during treatment often appears to be a more implicit process. However, it is essential to be consciousLy aware of the goals of each intervention and the current precautions. The physiotherapist needs to be alert both to possible beneficial changes as well as to certain undesired side-effects .
'Nothing at the price of If passive movement techniques are being employed, the goals of treatment may often be control or diminution of pain, or normalizing the range of motion; however, 'nothing at the price of' for example: -
•
inflammatory signs (be alert to redness, swelling, temperature)
(e.g.
increased fear avoidance
Pain responses during the application of passive movement techniques Two pain responses may occur while performing a technique: •
•
the pain may be felt in rhythm with the oscillations of the technique an ache may develop during the application of the technique.
It is difficult to distinguish between pain in rhythm with the technique and pain that may be increasing, because misunderstandings between the physiothera pist and patient occur easily. The easiest way for the physiotherapist to make this assessment is to ask the patient, while performing the technique • •
'Does-it-hurt-each-time-I-move?' or 'Is it in rhythm with what I'm doing or is it a constant feeling that is increasing as I continue?'
In cases of irritability of the pain the physiotherapist is usually mindful not to provoke any pain or discomfort during the application of a technique; however in cases where the condition is more stable and the pain
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L shows an 'on-off' behaviour more towards the end of the available range of movement, it may be beneficial that symptoms are provoked during the application of the technique. The physiotherapist will often posi tion the joint in an end-of-range position and perform oscillatory techniques towards the end of the available range of that technique. It needs to be emphasized that these symptoms should be occurring in the rhythm of the technique and once the technique is released (e.g. the technique is performed in a smaller grade or the joint is taken out of its end-of-range position), the pain should subside almost immediately. If symptoms increase independently of the rhythm of the technique, the physiotherapist needs to ascer tain that the condition of the patient is not worsening a change in the rhythm, speed, amplitude or position in range, or a complete change of technique may be needed. Notwithstanding if some symptoms increase for example in the lumbar spine while performing accessory movements in the spine - if, simultaneously, radiating symptoms in the calf or buttock decrease, then this may be interpreted as a favourable change and it is often useful to continue with the technique before any changes cease to take place. The assessments of what is happening while every technique is being performed must be recorded on the treatment record (Chapter 9).
PROG RESS IVE ANA LYTICAL ASSESSMENT: RETROSPECTIVE AND PROS PECTIVE ASSESSMENT It is essential to perform a regular review of the thera peutic process, in addition to the session by session (re)assessment procedures and forms of assessment during treatment. This is necessary to keep the right perspective of the patient's disorder. Some patients may state they feel much better when asked on a day-to-day basis. When asked after, for example, four sessions, 'How do you feel now com pared with four sessions ago?', the patient may answer after a long period of thought, 'I'm sure it's a bit better, at least it's certainly not any worse.' Such a retrospec tive answer makes the physiotherapist realize that not as much daily progress seems to have been made as originally thought. The opposite of course may also happen: the patient does not think he has made much progress, as he may still have difficulties cleaning windows. However, if asked in retrospect, for example, 'If you compare with, let's say 3 weeks ago, do you think you would have been able to clean those win dows?', then the answer may be, 'Oh no, it's certainly much better, because then I was not even able to lift my
arm long enough to wash my hair - now I am able to clean all the windows of the house. But of course, it was hurting.' This regular review of the therapeutic process is a reflective process and has several purposes: •
Reflections on all the decisions made.
•
Reflections on the generated hypotheses so far.
•
Analysis of the examination process so far.
•
Evaluation of the therapeutic interventions and their effects; determination if the therapy takes the course as originally planned, or if an adaptation of the treatment objectives needs to be made.
•
Evaluation of the educational process. (It is often worthwhile following a reflective process with the patient, similar to other educational processes [Brockbank & McGill 1998]. What has the patient learned so far and what was especially relevant in the therapy?)
•
If needed, reassessment relationship.
of
the
therapeutic
It requires communication skills to determine changes from the perspective of the patient and to (re)deter mine treatment goals. The therapeutic process may be considered as a navigation process in which it is neces sary to carefully monitor whether treatment goals have to be adjusted, which objectives have been achieved and to adapt the therapeutic interventions. At times, when spontaneous recovery or, on the contrary, no fur ther progression seems to be taking place, it may be useful to interrupt the therapy for approximately 2 weeks to assess possible changes without the addi tional interference of the physiotherapist. Retrospective assessments should take place: •
• • • •
at regular intervals (e.g. as a review of the therapeutic process in every fourth session if a patient is treated on an outpatient basis; if a patient is treated on a stationary basis of, for example, 3 weeks, then it is often useful to assess halfway through the treatment period) after a planned break from treatment if the therapeutic progress seems to stagnate to determine if treatment should be continued when spontaneous recovery seems to occur.
Retrospective assessment in review phases This should encompass information from the perspec tive of both the patient and the physiotherapist. First,
Principles of assessment
spontaneous information from the patient needs to be sought: •
•
•
Seeking spontaneous information from the patient: 'If you compare with about 3 weeks ago, how are you now in comparison with then?' It is essential not only to follow up changes in symptoms, but also to ascertain if the patient is able to perform daily life activities again, sometimes in spite of the pain. Effects of the treatment interventions: 'Of all the things we have done in therapy, is there anything that you think has been particularly helpful for you? Has there been anything that was not helpful at all or may have aggravated your problem?' What were the effects of the exercises, recommen dations and instructions given? Are there any diffi culties in the performance of certain self-management strategies? Do they reach the expected goals in all circumstances? (particularly if the objective of the interventions should be 'control over wellbeing' see AppendiX 2).
•
What have you learned so far from therapy?
•
It is essential to ascertain the level of activities and symptoms in comparison with not only the begin ning of treatment a few sessions ago but also with the worst period in the short-term history.
•
The symptoms and the level of activities have to be put in perspective to the period before the disorder had worsened. Some patients may have been con tent with a certain level of symptoms beforehand. In fact it may be even better than before, although not fully symptom free. To determine in such a case if therapy should be interrupted, the following questions could be asked:
Q '1 understand that you feel much better than before, but that it is not fully gone. How are you now in comparison with 6 months ago, before it all started?' A 'Well, I think that it's about the same again. It's back to normal.' Q 'Are you satisfied with it as it is right now, or would you expect any further improvement?' or Q 'Would you have sought help of a doctor or therapist, just as it is right now?' •
The physiotherapist should check the treatment records and determine which subjective and physical parameters ('asterisks') have changed after which interventions. It is emphasized that various interven tions may be necessary to normalize all parameters.
Prospective assessment After the review of the therapeutic process the therap ist should decide collaboratively with the patient on the treatment objectives for the next period of therapy. It may be useful to ask the patient some of the follow ing questions: •
'On which aspects should we work together now?' (The process of 'thinking from the end' as described in Chapter 4 may be useful in this stage of treatment.)
•
'Which activities need to get better?', 'Are there any activities in your work or hobbies which you do not have the confidence to do or need to be very careful in performing?', 'Which activities are still bothering you?'
•
Effects of self-management strategies: 'Do you feel the exercises I've shown you are effective enough in daily life?'
If new treatment objectives have been defined (e.g. the patient does not have enough confidence yet in bend ing down during his work as an electrician, or would like to play golf again), the activities may be used as physical parameters ('asterisks') during reassessment procedures in order to be able to guide the patient to the experience that the activities may be improving.
If therapy seems to be stagnating At times the treatment seems to stagnate or does not seem to bring the desired results. The physiotherapist needs to consider the following reflections in such a case: •
Have 1 compared the subjective and physical parameters in sufficient detail?
•
Did 1 follow up the right physical asterisks? (For example, instead of pursuing parameters which reproduce the patient's symptoms with, for example, 'combined movements', parameters are being fol lowed up which seemed to be comparable signs, but are now shown to be irrelevant - see Chapter 6.)
•
Have 1 performed a review of the therapeutic process with a retrospective assessment, collaboratively with the patient?
•
Has the right source of the symptoms been treated?
•
Have the self-management procedures been pursued profoundly enough? Did the procedure provide the patient with sufficient control over their wellbeing on all daily life situations? (Appendix 2).
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[ The following questions may be asked: •
•
•
• • •
•
•
• •
When does the patient consider that the condition stopped improving? Why does the patient consider the improvement stopped? Does the patient think that progress has occurred with earlier treatment? At what stage did the improvement take place? Was the improvement progressive? Which intervention seemed to have brought some progression? How does the patient feel now compared with before treatment began? How does the patient feel now compared with how he was before the onset of the episode? Does the patient think he is back to his normal? What treatment goals need to be achieved from this session onwards?
Once the therapist has determined the patient's opin ion in relation to all of the above-mentioned questions, it is the right stage to start a full re-examination, both subjective and physical, with the following questions: • • •
•
•
'What is your problem at this stage?' 'When does it bother you most?' 'Is there anything you can do here and now to demonstrate to me a way in which you can provoke the symptoms?' 'Are there any other aspects of your symptoms, or the ways in which they affect you, that you think might be helpful to my understanding of your problem?' 'If you have symptoms, is there anything you do by yourself - even instinctively - to ease them?'
Planned break from treatment Many patients have a disorder that may not be fully normalized in every regard. Under such circumstances the end result of treatment will be a 'compromise result'. It is not easy to know when that compromise result has been reached. A time will arrive when the patient's symptoms do not continue to improve, and in fact there is a possibility that treatment perpetuates the symptoms. In this case the patient can be given a break from treatment of approximately 2 weeks, after which an assessment of the subjective and physical parameters can be made. If the symptoms have improved, the patient should be left for another 2-3 weeks or may be discharged on the assumption that the symptoms will continue to improve without treatment. If the symptoms and signs remained the same, the patient should be given four or
five more treatments and then taken off treatment again for a further 2 weeks. At the end of this period it will be possible to determine whether the extra treat ment produced any improvements and whether a further few treatments should be administered.
Conclusion: retrospective and prospective assessment A retrospective assessment as outlined above can take as long as any session. The searching for detail is important at this point, because during retrospective assessments important decisions may need to be made with regard to the future management of the patient's disorder.
FINA L ANALYTICA L ASSESSMENT Towards the end of the therapeutic process a final ana lytical assessment may need to be performed (Box 5.2). Frequently it is useful to prepare the patient over two or three sessions for the discharge of treatment. In the final stage of analytical assessment all the information of the therapeutic process should be analysed: • • • •
first examination behaviour of the disorder throughout treatment details derived from retrospective assessments state of affairs at the end of the treatment series, taking into account the changes in subjective and physical parameters.
In collaboration with the patient the clinician needs to make an assessment in relation to: •
•
•
•
•
•
reflection on overall therapeutic process - which interventions brought which results? reflection on learning process - what was especially important for the patient and what has been learned? the effectiveness of any prophylactic measures and self-management interventions compliance-enhancement strategies - which self management interventions are especially beneficial?; in which situations would the patient anticipate any difficulties in the future?; which activities/ exercises would the patient resume in the case of recurrence of symptoms? suggestion of any medical or other measures that can be carried out prognosis on possible remaining functional deficits on impairment, activity and/ or participation levels (ICF - WHO 2001).
Principles of assessment
Box 5.2
Overview of the various forms of assessment and their objectives
Assessment at first consultation
Assessment d uring treatment
•
•
Determination of the physiothera py-specific diagnosis:
•
•
Finding causes and contributing factors to the
mobilizations, monitoring of the changes in the
movement disorder of the patient
behaviour of pain, resistance or motor responses ('spasm')
Ma nagement: determination of goa ls of treatment, selecting meaningful interventions
•
Develo pment of a therapeutic relatio nship: motivation, respecting the i n dividu a l illness experience, co l l aborative goa l setting
•
Determination of any preca utions a n d / or contra indications to physical exa m i n ation procedures or therapeutic interventions
•
•
such as: pathobiological processes, i n clud i n g
assessments (regular review of the thera peutic process in add ition to the session-by-session reassessments) •
contributing factors precautions a n d contra ind ications i n d ividual illness experience
have im proved so far; which ones have remained •
Are agreed treatment objectives being achieved ?
•
W h a t has the patient learned so fa r? W h a t was pa rticularly i m porta n t to the patient in the learning process?
•
D u ring the initial exa m i nation phase after the tests
•
•
(col laboratively with the patient) •
Final a nalytical assessment •
process: reflection on overall therapeutic process: wh ich
I m mediately after the a p p l ication of the various
interventions brought which results? reflection on learning process: what was especia l l y
interventions; includes interventions such as
i m porta nt for t h e patient - w h a t has been learned?
information a n d education
•
•
•
the effectiveness of any prophylactic measures a n d
At the end of the treatment session
self-ma nagement interventions •
Prospective view: a nticipation of possible difficulties /
Comparison of treatment results - proving the va l u e of
enha ncement strategies of lo ng-term com p l i a n ce with
the selected interventions
advice, self-ma nagement measures and exercises : com pliance enha ncement strategies: Which self
Differential d iagnosis: by reassessment of therapeutic interventions a contribution to differential d iagnosis is
m a n agement i n terventions a re especially
provided
beneficia l ? I n which situations would the patient
Enable the physiotherapist to reflect on the decisions
a n ticipate a ny difficu lties in the future? W h ich
made; enha nce the development of c l i n ical patterns in
activities / exercises would the patient resume in the case of recurrence of symptoms?
memory, hence support of the develo pment of the experiential knowledge base •
Review of the whole therapeutic process, includ ing statements of the patient on the i n d ividual lea rning
At the begi n ning of each subsequent treatment
Purposes
(Re)determination of the para meter to monitor the agreed goals of trea tments
treatment interventions - proving the value of the
•
Prospective assessment: (re)determination of treatment objectives for the next period
session •
Monitoring the effect of the various treatment i nterventions
Reassessments exa mination of various active and passive movement
Which su bjective a n d physical pa rameters ('asterisks') uncha nged?
management (objectives, interventions) prognosis (short term, long term)
Assessment of the overall wel l being of the patient in compa rison with first sessions
•
neu rophysiological pain mechanisms sources of symptoms a n d movement dysfunctions
Avoidance of u n d esired side-effects
Progressive analysis: retrospective and prospective
Procedura l c l i n ica l reason i ng: the assessment p rocess is guided by the genera tion a n d testing of hypotheses
•
Determination if the objectives of the intervention are being achieved : during the appl ication of passive
expressed i n terms of movement dysfunctions
•
Prognosis on possible rem a i ning functional deficits
Support of the learning process of the patien t : in
on i m p a i rment, activity a n d / or participation level s
reassessment procedures in combination with careful
(ICF - WHO
com m u n ication, the patient may be enab led to experience beneficial cha nges
•
1 99 1 )
Suggestion of a ny medical or other measures that ca n be carried out
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ASSESSMENT AND CLINICAL R EASONING Analytical assessment and clinical reasoning may be considered as twin elements of the therapeutic process. The description of physiotherapy by the World Confederation of Physical Therapy (1999, p. 7) reflects the basic principles of this concept regarding assess ment and clinical reasoning, as follows:
Assessment includes both the examination of individuals or groups with actual or potential impairments, junctional limitations, disabilities or other conditions of health by history taking, screening and the use of specific tests and measures and evaluation of the results of the examination through analysis and synthesis within a process of clinical reasoning. As described in Chapter 4, physiotherapists may employ various forms of clinical reasoning. Within the diagnostic process and determination of treatment, procedural reasoning with a process of hypothesis gen eration and pattern recognition frequently plays a cen tral role (Payton 1987). The other forms of clinical reasoning frequently used include (Edwards 2000, Jones & Rivett 2004): • • •
interactive clinical reasoning conditional clinical reasoning narrative reasoning.
It is considered that the various strategies of clinical reasoning are in an intrinsic relationship in clinical practice, in which the physiotherapist moves between the various forms of reasoning to shape an optimum examination and treatment process collaboratively with the patient (Edwards et al 2004). Procedural rea soning, which is principally cognitive based and involves a process of hypothesis generation and test ing, aids the diagnostic process and treatment plan ning. Forms of narrative and interactive reasoning resulting from an interpretive paradigm are frequently employed to develop a deeper understanding of the patient's individual experience regarding pain and disability, including beliefs, thoughts, feelings and sociocultural influences.
knowledge base, as experienced therapists are more likely to engage in interactive processes in contrast to novices who tend to be more mechanical and proced ural in their encounters with patients during a thera peutic process (Jensen et al 1990). It has been proposed that empathy does not necessarily increase over the years of clinical experience; however, interactive skills training is more likely to enhance this in experienced physiotherapists (Thomson et al 1997) . It is emphasized that a balance between procedural and interactive reasoning is necessary in order to shape a constructive therapeutic relationship as a basis for the physiotherapy process.
Narrative clinical reasoning Various forms of narrative reasoning may be employed in the educational and therapeutic processing of the patient. It may be employed consciously in order to allow patients to give their own account of the disabil ity and pain rather than being controlled by strict crite ria in which patients are only allowed to talk about those aspects which serve the physiotherapy diagnosis (Thomson 1998). It has been suggested that the interpretation of the individual story should be a core task in medicine; neglect of individual narratives may lead to alienation of the patient from the care giver (Kleinmann 1988). The diagnostic process may be positively influ enced if the therapist gives space to the personal story and experience of the patient, as a mutual understand ing between therapist and patient is more likely to unfold and the therapist gains insights into those aspects that are truly meaningful to the patient. Furthermore, narratives may be intrinsically thera peutic, as they aid the patient in gaining a deeper understanding of the individual experience. Addition ally, they may allow for a multidimensional approach to treatment, as the thoughts, beliefs, preferences and sociocultural context of the patient may be taken into consideration (Greenhalgh & Hurwitz 1998). The deliberate application of narrative reasoning may be an art, and may be easier to apply if mastery has been achieved in procedural reasoning and inter active reasoning, with well-developed communication skills and careful observation of key gestures or sensi tive listening to key words and phrases.
Interactive clinical reasoning Interactive clinical reasoning may be employed for various purposes, as described in Chapters 3 and 4. It takes place during the direct encounters between the physiotherapist and the patient. It seems to have become an aspect of a more implicit, experiential
Procedural clinical reasoning The basic procedures of examination, assessment and (treatment) planning as outlined in this book may be considered as an expression of procedural clinical rea soning processes. From a cognitive point of view, the
Principles of assessment
problem-solving processes of physiotherapists appear to be based on hypothesis generation and/or clinical pattern recognition. For many years it has been a prin ciple of the Maitland Concept to generate hypotheses which guide decisions regarding examination and treatment procedures; however, it is recommended that physiotherapists categorize the generated hypoth eses ( Jones 1989) and make them explicit in the various planning stages of the therapeutic process.
Hypothesis deduction and induction In many problem-solving processes it has been recog nized that most adults generate hypotheses based on a process of cue acquisition (Elstein et al 1978). Within manipulative physiotherapy assessment these cues may be derived from various sources of information: •
•
•
• •
The patient, with non-verbal and verbal expressions as well as movement behaviour. Based on this information, physiotherapists may start to generate multiple hypotheses (e.g. prognosis, level of disability, illness experience from the first moment of the encounter between patient and therapist). Referral form with the medical information and possible questions of the referring clinician. Subjective examination with information regarding the pain, activity limitations and participation restriction, history of the disorder, general health, etc. Physical examination procedures. Treatment, including the various reassessment procedures.
It has been emphasized that the process of hypothesis generation and testing is a cycl ical process in which the physiotherapist develops an initial concept of the patient's problem, with mul tiple hypotheses from the very first moment of the encounter between patient and therapist. During the process of both the subjective and the physical exami nation the process of hypothesis generation is conti nued, with a modifying, rejecting and confirming of the various hypotheses (Jones 1989). Reassessment pro cedures are essential in this process, as they may con firm certain hypotheses or may signal the need to modify the hypotheses. By consequent reassessment and reflection, the process of testing hypotheses may contribute to the development of clinical patterns in memory as part of the experiential knowledge base (Higgs 1992). However, from a client-centred perspective not only physiotherapists but also patients frequently go through a cyclical process of hypothesis generation as Cyclical
process
the therapeutic and educational processes progress (Edwards 2000), which has to be taken into conside ration during all interactions.
Categorization of hypotheses In many problem-solving processes the information is organized into meaningful clusters of data (Larkin et aI 1980). In contrast to j unior physiotherapists, more experienced therapists organize the information dur ing subjective and physical examination processes into relevant categories. This frequently enables them to find a more comprehensive overview of a patient's clinical presentation (Thomas-Edding 1987) and allows the shaping of more meaningful treatment plans. Physiotherapists are therefore encouraged to organize the information of the various steps in the therapeutic process into hypothesis categories (Jones 1989). Although the process of hypothesis categorization in principle is an individual process (Larkin et aI 1980), in manipulative physiotherapy, within a biopsycho social movement paradigm, many therapists may employ similar hypothesis categories as outlined in Box 5.3.
Reflection Within the process of hypothesis deduction and induc tion, reflection or metacognitive skills are essential. It is crucial to reflect regularly on the hypotheses gener ated in critical phases of the therapeutic process. Hypotheses need to be made explicit and reflected upon in the following phases: •
•
• • •
after completion of the subjective examination as a preparation for the physical examination after completion of the physical examination and the initial treatment as a preparation for each subsequent session during retrospective assessment at the final analytical assessment in the last treatment session(s).
Without reflection, certain hypotheses may be favoured or others may be neglected Gones 1997). A lack of reflection may lead to automatic actions without any lateral thinking (De Bono 1970) or trying something unexpected in the solving of a particular problem. By regular, disciplined reflection procedures clin icians may uncover habitual practice, follow up changes in their personal clinical development and may discover the need for a next step in professional education. Critics may debate that there is 'nothing new under the sun' with clinical reasoning. However, if the rich ness of thoughts and feelings underlying therapeutic
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[
Box
Hypothesis categories frequently used in manipulative physiotherapy prac:tlce
5.3
Pathobiological processes
Sources of movement dysfunctions and pain
This category may include various data relating to tissue
The movement components from which nociceptive
processes and neu rophysiological pain mechanisms:
and peripheral neu rogenic pain processes can be
•
Pathological processes (e.g. inflammation, instability) : serving biomedical diag nostics and the determination of certai n precautions or contraindications to examination and treatment proced ures
•
Stages of tissues healing : information regarding the clinical presentation in relation to the correspon ding stages of tissue healing ; early stages of tissue healing after trauma are indicative of precautions to examination and treatment proced u res; in ongoing pain states, tenderness or inflammatory presentations which may have been present m uch longer than wou l d be expected from normal hea l i n g stages; other factors (e.g. central nervous system mod ulation, autonomic mechanisms,
•
reproduced or movement dysfunctions such as stiffness, hypermobil ity or lack of muscular control may be detected. This category includes the following fu nctions and structures contributing to the movement disorder of the patient: •
joints (local, referred)
•
m u scles
•
neu rodynamics
•
soft tissues
•
viscera, blood vessels
Contributing factors Relate to the predisposing or maintaining factors to the patient's problem. They include physical, biomechan ical,
behavioural factors) may contribute to the p resentation
environ mental, social, emotional, cognitive and / or
Pai n mechanisms relating to the neurophysiological
behavioural factors.
mechanisms u n d erlying the patient's pain experience and d isability - see the matu re organism m odel (Gifford 1 998b) and the processing model (Shacklock 1 999a) : ' i n p u t mechanisms' to the central nervous system may relate to, for exam ple, nociceptive mechanisms or perip heral neurogenic mechanisms central nervous system mod u lation will always take place; however, the central nervous system processing (plasticity) may become a dominant, ongoing factor in
the pain experience due to pathobiological,
cognitive, affective or learning p rocesses. Ongoing pain states, tenderness and d isability may be the resu lt 'output' mechanisms relate to physiological processes (e.g. au tonomic, i m m u ne or endocrine reactions) ; output processes result in motor reactions and behavioural aspects (e.g. movement patterns, help seeking, expression, avoidance behaviour) Precautions and contraindications to examination a n d treatment procedures Mostly determi ned by pathobiolog ical processes and neu ro physiological pain mechanisms. The following factors may be included :
Level of disability Determined by terms of i m pairments, activity limitations and / or participation restriction as defined in the International Classification of Functioning, Disabilities and Health (WHO
200 1 ) .
Individual i l l ness experience Consideration of the patient's beliefs, thoughts, feelings, emotions, earlier experiences, influence on the social environ ment, influence from the social environ ment, val ues, meanings, attribution and behavioural factors as well as coping strategies. Management Determined by all other hypothesis categories. Relates to a l l decisions regarding definition of treatment objectives and selection of meaningful i n terventions to g u ide patients towards a sense of health concerning .movement fu n ctions. Goals may include: •
normalization of movement im pairments (symptoms, sig ns)
•
normal ization of the level of activities and partici pation
•
pathobiological processes
•
•
irritability of the disorder
•
prevention of new episodes
•
severity of the disorder
•
awareness of use of self, relaxation
•
self- management strategies regard ing control over
•
cog n i tive goals regarding knowledge and beliefs about
•
stage and stabi lity of the disorder
•
general health
•
patient's movement behaviour, perspectives and expectations
trust in use of body
pain or wellbeing the pain and the fun ction of movement in treatment
Principles of assessment
Prognosis: for first 3-4 sessions/overall process / a fter
•
mechan ical versus i n fla m matory presentation
completion of therapeuti c process
•
relations h i p between i m p a irments, activity l i m itations
Prognosis takes place in various phases: •
Short term : Wh ich results may be expected within the first 3-4 sessions (part of c l i n i cal pattern recognition)?
•
What may be expected after co m p letion of the thera peutic process?
•
pre-elSisting d isorders (e.g. degenerative c h a n ges and a n i njury or m isuse of the knee)
•
patient's beli efs, expectations, e a rlier experiences patient's lifestyle and movement behaviour
either short- 'or long-term prognosis:
•
contri buting factors - 'cause of the source' (e.g.
•
stage of tissue healing a n d damage
•
general health, general fitness level
Based on various studies in clinical reasoning, it has been illustrated that next to the process of hypothesis generation and testing, other processes are being employed in clinical decision making: experts, in con trast to novices, may instantly recognize a situation and may be capable of selecting meaningful treatment interventions by the recognition of clinical patterns (Norman & Patel 1987). Clinical patterns are frequently described in rela tion to a pathobiological paradigm; however, they may include many more aspects (Hengeveld 1998, 2000):
•
of the d isorder and progression of the d isorder (are attacks more freq uent or d isa b l i ng?)
•
Clinical patterns: illness scripts
•
onset of the d isord er, d u ration of the h i story, stability
N u m erous factors have to be taken i nto consideration i n
actions and interactions is not made explicit, the risk exists that the daily practice stagnates in automatic patterns of decision making and professional develop ment is restricted (Ryan 1996). Consequent reflection on the clinical reasoning processes in regular planning stages of the therapeutic process should lead to a more comprehensive and efficient clinical practice.
•
uni- or m u lticomponential move m e n t d isorder
•
Wh ich results may be expected d u ri n g the overa l l process of physiotherapy?
•
and participation restrictions •
pathobiological processes, including the consequences for physical examination and/ or treatment procedures uni- or multicomponential movement dysfunctions approach to treatment. Is a more one-dimensional approach to treatment possible (see Fig. A2.1, Appendix 2) or does a multidimensional approach seem necessary, with a conscious shaping of the communication and behavioural approach to the procedures of examination, treatment and reassessment? If a more multidimensional approach to treatment seems necessary the clinician may deliberately choose an approach of narrative
posture, muscle weakness or tightness, d iscrepancies in mobil ity of joint com p l exes such as spine or wrist, etc.)
reasoning in the initial phase to allow patients to give their own account of the problem. In research on the development of clinical patterns over the years of clinical experience, it has been sug gested by Schmidt and Boshuyzen (1993) that clin icians go through various phases in the development of expertise: 1 . Accumulation of causal knowledge about disease and its consequences. 2. Through experience with real patients this knowledge transforms into narrative structures or 'illness scripts' ('encapsulation of knowledge'). 3. Use of episodic memories of actual patients in the diagnosis of new cases. They postulate that knowledge acquired in different phases forms layers in memory which remain available for use if the recent layers in memory fail to support the process of decision making. The lived experience with actual patients seems to contribute to the develop ment of clinical patterns and the instantaneous recog nition of what to do in clinical situations. Many clinicians may not be aware of the effects of clinical experience and memories of direct encounters with patients in their decision-making processes. In order to be able to successfully make use of clinical patterns and illness scripts over the years of clinical experience and 'reflect in action' (Schon 1983), clin icians need to have developed a profound theoretical knowledge base and experience of clinical examina tion, treatment and reassessment procedures. If, within the clinical presentation of a particular patient, no patterns are recognized or actual patients remem bered, clinicians need to employ the basic procedures within a process of regular 'reflection on action' (Schon
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1 14
M A I T LA N D ' S P E R I P H E R A L M A N I P U LAT I O N
Individual stories ('Illness scripts') Clinical pattems Procedures of examination a.!"� ��! ���i �
_ _ _
_ _ _
Theoretical knowledge base Figure 5.3
Differences between experts and novices
, """\
....I
D
Hypotheses generation and testing, including reflection In actual encounters with patients
Development of clinical pattern s and i l l n ess scri pts
Over several decades numerous reasoning studies have been undertaken to investigate how experts differ from novices and how they acquire this expertise. It has been recognized that experts distinguish themselves from novices in various ways: •
Experts may have better treatment results, with more efficient problem-solving processes.
•
Experts may employ various forms of reasoning.
•
Experts seem less procedural in their approach to the patient and seem capable of more active inter active reasoning in the shaping of a therapeutic relationship.
•
Experts seem to have a better organized and acces sible knowledge base, with theoretical and clinical aspects: more clinical patterns and the employment of 'forward reasoning' with so-called 'if . . . then . . . ' rules.
•
Experts may have more patient stories in their memory and make use of them in decision-making processes.
•
Experts allocate more time for qualitative problem analysis (illness experience).
•
Experts seem to be bothered less by distractions in the therapeutic process in the application of proce dures and in interactions with patients.
•
Experts allow non-verbal cues to play a decisive role in decision making.
•
Experts develop reflective skills.
•
Experts employ both creative and lateral thinking.
•
Experts are aware of the strengths and weaknesses in their own actions and individual clinical reason ing processes.
in memory. By actual l y going through procedures of examination, treatment and reassessment, clinicians are in a direct encou nter with patients and their ind ividual stories. This appears to contribute to the development of different layers in cl inical memory which are accessible in decision-making processes with future patients. Clinicians appear to use memories of actual patients in diagnosis: if no memories of actual patients are present, they may approach the layer of cli nical patterns in memory; if no clinical patterns can be recog nized or actual patients remembered, clinicians may need to employ basic procedures of assessment and seek advice in propositional knowledge. Adapted from Schmidt & Boshuyzen
(1 993)
with kind permission from Springer-Verlag.
1983) and integrate planning phases in the therapeutic process (Fig. 5.3). Pattern development by 'trial and error' In the process of acquiring clinical patterns in memory (making them available in future decision-making processes), clin icians need to analyse their decisions frequently (Watts 1985, 2000) in the regular planning phases of the thera peutic process. The various hypotheses regarding sources, con tributing factors and treatment interventions need to be employed and scrutinized in reassessment pro cedures. Novices, in order to gain experience, should not take any shortcuts, but make the actuaL experience collaboratively with the patient about which interven tions on which source may bring the desired results. It has been said that, within reassessment proced ures, physiotherapists go through a simple 'trial-and error ' process; however, deliberately following up hypotheses and consequently subjecting them to reassessment procedures is in a sense heuristic: based on information from the subjective examination on the localization of symptoms (the 'body chart' - see Chapter 6), the physiotherapist may for example gen erate various hypotheses on the sources of the symp toms. At the stage of information gathering concerning 'behaviour of symptoms', the physiotherapist may endeavour to 'make features fit' and to confirm or reject certain hypotheses based on the analysis of the activ ities which provoke the symptoms. Frequently this heuristic process will aid the physiotherapist in setting priorities in initial physical examination procedures.
(Adapted from: Patel & Groen 1986, Jensen et al 1990, 1992, Schmidt & Boshuyzen 1993, Mattingly & Fleming 1994, Ryan 1995, Jones 1997, King & Bithell 1998, Jensen et aI 1999.)
Conclusion: procedural clinical reasoning Based on the insights gained from clinical reasoning research, it may be concluded that a process of continu ous assessment, reflection and consequent pLanning may guide novices on their path to clinical expertise. Pre requisites to this process are well-developed clinical examination and treatment skills, communication skills and a comprehensive, accessible, updated theoretical knowledge base. For further reading see Mattingly & Fleming (1994), Higgs & Jones (2000) and Jones & Rivett (2004).
Principles of assessment
PSYC HOSOCIAL ASSESSMENT AS AN INTE G RAL PART OF T H E P H YSIOT HERA PY ASSESSMENT With the shift to a biopsychosocial paradigm, the indi vidual illness experience with the person's thoughts, feelings, sociocultural context and illness behaviour is progressively taken into account in the shaping of treatment. Furthermore, with the dramatic increase of pain related disabilities in many industrialized countries it has been recognized that psychosocial factors in par ticular are frequently relevant contributing elements in such chronic conditions (Turk 1997, Linton 2000). Therefore it is recommended that physiotherapists perform an assessment to establish those psychosocial factors that hinder full recovery of function ('yellow flags') in those patients who are at risk of developing a chronic disability due to pain (Kendall et al 1997). It has also been recommended that physiotherapists should assess psychosocial contributing factors and integrate these into the rehabilitation of patients with movement disorders (Scalzitti 1997, Wright 1999, Simmonds et a1 2000, Watson & Kendall 2000). It appears that experienced phYSiotherapists impli citly adhere to a biopsychosocial paradigm and seem to have developed a 'tacit', experiential knowledge base regarding the psychosocial aspects of their work (Hengeveld 2000), calling this 'good patient handling skills' (Watson 1999). However, it seems that they may not always be explicitly aware of their actions and inter actions in this context Gensen et al 1990, 1992) and may have insufficiently conceptuaLized the psychosocial dimen sions within the phYSiotherapy-specific paradigm of movement rehabilitation with the instruments of move ment, touch and other applications (Hengeveld 2000).
Objectives of psychosocial assessment in physiotherapy The first objective is to establish any psychosociaL risk factors ('yellow flags') that may hinder patients with pain in their recovery to full function. A person is con sidered at risk of developing long-term disability due to pain if, on clinical presentation, there are one or more very strong indicators, or several less important but cumulative factors, of risk (Kendall et al 1997). Psychosocial assessment may also give insights into the world of the individual illness experience, which may assist in the process of collaborative goaL setting. Treatment objectives on activity levels can be defined throughout the subjective examination if certain ques tions regarding the patient's personal experience and beliefs are followed up and summarized with skilled communication strategies (see also Chapter 3).
A psychosocial assessment, with attentive listening skills and careful observation, may allow for a multidi mensionaL approach to physiotherapy management in which the patient may be guided to a sense of health and health-promoting behaviour regarding movement functions. In this phenomenological perspective to physiotherapy treatment, cognitive, affective, socio cultural and behavioural factors need to be conceptu alized next to physical aspects of movement functions (see also Chapter 4 and Appendix 2).
Yellow flags The psychosocial risk factors have been described in various publications (Kendall et al 1997, Watson & Kendall 2000, Waddell 2004). They have been described in a mnemonic 'ABCDEFW' in an order of conven ience, which does not necessarily indicate a ranking in relative importance (Kendall et aI 1997). Some aspects which may be of particular interest to physiotherapy practice are described in Box 5.4.
Misconceptions regarding psychosocial assessment and the b iopsychosociaJ framework Some misconceptions with regard to psychosocial assessment may lead to misinterpretation of informa tion. This may be attributed to the lack of conceptual ization as the shift to a biopsychosocial paradigm may not have completely taken place in the medical and physiotherapeutic world.
Yellow flags It is critical to aVOiding pejorative labelling of patients with yellow flags as this will have a negative effect on management and the attitudes of the clinicians (Kendall et aI 1997). Predicted poor outcomes in acute nociceptive pain states with the presence of relevant yellow flags should lead to different approaches (e.g. cognitive-behavioural approach, interdiscipli nary approaches) to treatment rather than denying therapy or shifting patients over to psychiatrists.
Central pain Based on insights from neurophysiological pain mech anisms, clinicians may use the term 'central pain' or 'central pain patient' as a substitute for the obsolete term 'psychogenic pain'; however, using the term 'cen tral nervous system modulation' has been suggested. As soon as clinicians develop hypotheses regarding central nervous system processing contributing to the pain experience, they have to consider all possible
115
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M A I TLAN D ' S P E R I P H E R A L M A N I P U LAT I O N
L Box
I
5.4
Psychosocial risk factors to long-term disabi l ity with relevance to physiotherapy practice -
Attitudes and beliefs a b o u t pain •
avoida nce behaviour (e.g. the development of g u a rding •
Diagnostic language leading to catastrophizing
•
Dramatization of back pain by health professional
and fear
movements and fea r of movement)
prod ucing dependency on treatments, and
Belief that a l l pain m ust be a bol ished before
continuation of pa ssive treatment
attempting to retu rn to work or normal activity •
•
Belief that pain is h a rmful or disabling resulting in fear
•
Expectation of increased pain with activity or work,
Advice to withdraw from job a n d other releva nt activities
lack of a bility to predict capa bility •
Catastrophizing, thinking the worst, misinterpreting
Emotions
bodily symptoms
•
•
Bel ief that pain is u nco ntrolla b l e
•
Long-term low mood, loss of sense of enjoyment
•
Passive a ttitud e t o re h a bilitation
•
Anxiety a bout and heightened awareness of bodily
•
Feeling u nder stress and u n a ble to maintain a sense
Behaviours •
Use of extended rest, disproportionate 'downtime'
•
Reduced activity levels with significant withdrawal from activities of daily livi n g , avoid a n ce of normal activity a n d prog ressive substitution of lifestyle away from prod u ctive activity
•
Irreg ula r pa rticipation or poor co m p liance with physica l exercise
•
Excessive reliance on use of aids or a p p l i a nces
•
Increased intake of a l cohol or other su bstances since onset of pain
Fear of increased pain with activity or work
sensations of control •
Feeling useless a n d not needed
Family •
Overprotective partn er/ spouse; solicitous behaviour of spouse (e.g. ta king over tasks)
•
Extent to which family mem bers support a ny attempt to return to work or other releva nt activities
•
Lack of su pport person to talk with about problems
Compensation issues
Work
•
Lack of fi n a n cial incentive to return to work
•
•
History of cla i m (s) due to other pain problems
mai ntenance of constrained or sustained postures;
•
Previo us experience of ineffective case management
inflexible work schedule p reventing appropriate breaks
(e.g. a bsence of i nterest, perception of being treated
•
pu n itively) Diagnosis and treatment •
•
Experience of conflictin g dia g n oses a n d exp l a nations, resulting i n confusion
pathophysiological, cognitive, affective, sociocultural and behavioural contributions.
Causative agents and contributing factors Within the dualistic biomedical model a causative approach to examination and treatment exists. How ever, within a biopsychosocial model there needs to be a distinction between causative agents and contribut ing factors. For example, a person with a history of sexual abuse and long-lasting pain in the hip and back area may have developed a certain sensitivity as a contributing factor. The person will certainly not be
Belief that work is h a rmful, that it will do da mage or be d a ngerous
•
Min i m a l ava i l a bility of selected duties and g rad uated retu rn to work path ways, with u nsatisfactory
H ea l th professionals sanctioning disability, not providing interventions that will improve function
job i nvolvi ng high biomechanical demands with
imp lementation of these •
Absence of i nterest of employer
Adapted
from Kendall et a l
(1 997).
helped in finding a sense of control over their well being if the clinician treats this history as a causative factor and withdraws from treatment without guiding the patient to a sense of control and increased bodily awareness in different situations.
Psychopathology Patients with a chronic pain experience may have dif fering scores in investigations into psychiatric diag noses such as depression, anxiety disorder or personality disorder; however, it has been recognized that these psychiatric presentations seldom explain the pain fully
Princip les of assessment
(Large 1996). It is argued that all too often personality
traits are mistaken for personality disorders as cat egorized in DSM-IV (Weisberg & Keefe 1997). The psy chosocial assessment is not a psychiatric assessment for psychopathology, personality disorders or social problems. This would be indicative of so-called 'orange flags' and patients should be referred to the appropri ate psychiatrist or psychologist (Main 2004). It is essen tial not to label chronic pain patients as psychiatric patients, nor to seek after pain-prone personalities, but to recognize that most chronic pain patients show nor mal psychosocial variables of the human experience which contribute to pain and disability (Linton 2000). Psychosocial assessment may be considered as an investigation into normal cognitive, affective and socio cultural variables of the human experience which may hinder the full recovery of ftmction due to pain perception and behaviour. Psychosocial yellow flags should be integrated into management and not mis used to stigmatize patients or used as an excuse to withdraw from a patient's care.
Life problems Social or marital problems and other challenging life situations may not necessarily be yellow flags. It is essential to consider if a patient is capable of recogniz ing these factors as such and is able to cope with them actively.
Secondary gain
strategies (Sluys 2000, Moseley 2004) in influencing the beliefs of the patient. However, there may be more pain- and disability related constructs that may need further conceptualiza tion in future physiotherapy practice (Hengeveld 2000). Some of these constructs are delineated in Box 5.5.
Questionnaires or interviews as an integral part of physiotherapy assessment It is postulated that every clinician should be capable of performing a screening of yellow flags (CSAG 1994) and various physiotherapists advocate the integration of this investigation into the overall assessment of physiotherapists (Scalzitti 1997, Watson 1 999, Simmonds et aI 2000). Several questionnaires have been developed to assess psychosocial aspects, such as the Fear Avoidance Beliefs Questionnaire (Waddell et a1 1993) or the Acute Low Back Pain Screening Questionnaire (Linton & Hallden 1996), and many others. Questionnaires may have some advantages as they may provide a clinician with preliminary information, which can then be followed up in further detail during the clinical interview. However, it is emphasized that psychosocial assessment should be an integral part of the overall physiotherapy assessment and treatment process, which carmot be replaced by any question naires. The integration of a psychosocial assessment in the interview may have several advantages:
Relevant psychosocial constructs in physiotherapy practice
• Clarifications can be sought. For example: Patient 'I just carmot do anything about this pain!' Therapist 'Do I understand that you feel you have hardly any control over your wellbeing?' 'Yes, that's so - it's terrible!' Patient Therapist 'Would you agree to our trying to find measures or movements that you could perform yourself to keep some sort of control?' 'Oh yes.' Patient Therapist 'Okay, which activities do you feel are mostly out of your control?' • The information may be used in the process of collaborative goal setting to define meaningful treatment objectives. • It encourages the development of trust, mutual understanding and the shaping of the therapeutic relationship.
It appears that the explicit conceptualization of psy chosocial factors in physiotherapy practice is on its way with, for example, the awareness of cognitive behavioural approaches in physiotherapy (Harding & Williams 1995) and the relevance of educational
There is some indication that psychosocial assessment may already be part of the implicit, experiential know ledge base of physiotherapists. However, it appears that the assessment is more likely to be performed intuitively in an exclusive way. If a patient is shown to
Secondary gain is described as a social advantage attained by a person as a consequence of an illness; however, tertiary gains may also exist in which others in the direct environment benefit from the illness of the person. It is important not to focus solely on the second ary gain of a person with pain without asking about the secondary losses to the person as well (Fishbain 1994). Exaggerated pain behaviour may often be taken as malingering or secondary gain. However, it is emphasized that real malingering is rare; exaggerated pain behaviour can exist for various reasons and is judged as such from the perspective of the clinician rather than the patient (Pilowsky 1997).
1 17
1 18
M A ITLAN D ' S P E R I P H E R A L M A N I P U LAT I O N
[
Box & . 8 Differea t pIydtosodaI � possibly needing further conc:eptualttat'l on In the physiotherapy process • •
D ifferences between pain, disa bility a n d suffering Behaviour (illness beh avio u r ; health-promoting behaviours) : exp ression a n d g uarding move ment patterns avoid a n ce h e l p-seeking confronting boom-busting
•
Coping strategies: active or passive (or: conscious or a utoma tic)
•
Emotions:
involvement of psychosocial contributing factors, it appears that conceptualization of these factors is insuf ficient to distinguish the different psychosocial aspects from each other and to develop specific treatment approaches from the movement perspective of the pro fession (Hengeveld 2000). In this section it has been postulated that psycho social assessment should be an integral part of the basic physiotherapy assessment as it will aid the physiother apist to recognize those patients at risk of developing chronic disability, but above all it serves the shaping of a multidimensional approach to treatment. The fol lowing aspects are prerequisites to performing psy chosocial assessment and management successfully: •
fear, a nxiety d e pressed mood
•
helplessness, h opelessness vulnera bility a n g er
•
g u ilt •
Cognition :
•
expectations catastro ph izing beliefs, knowledge self-efficacy beliefs •
Sense of control: locus of control ( i n ternalized, externalized) - self-efficacy beliefs
•
- coping strategies •
•
Learning processes: - earlier experiences (self, significa n t others)
•
- sociocultural influe nces a n d values •
Social aspects: - job satisfaction - sense of control - influence of spouse, relatives a n d social s u p port
•
skilled interviewing, examination and reassessment procedures the possibility to integrate forms of interactive and narrative reasoning, with well-developed communication skills careful observation of body language, posture and movements attentive listening and responding to key words and phrases: it is important to pay attention not only to what people say but also to how they say it and the words they choose to describe their experience communication skills (e.g. summarizing, questioning, mirroring; see Chapter 3) understanding of tl1e various psychosocial con structs as contributing factors to a pain experience conceptualization of theses constructs within the phYSiotherapy-specific movement paradigm.
Phenomenological dimensions: sense of coherence, sense of self, sense of the world, sense of wellbein g , sense of pu rpose
Integration in the physiotherapy process During various phases of the physiotherapy process it may be decided to explicitly integrate aspects of a psy chosocial assessment and management.
individual illness experience, i n divid u a l health experience Reproduced by kind permission from Hengeveld
(2000).
have symptoms in a clear stimulus-response relation ship, seems to cope well, is confident that the problem will get better and has not diminished the level of activ ity in daily life, physiotherapists may conclude that 'this is an uncomplicated sih.\ation', with a good prog nosis. Hence within this form of psychosocial assess ment many relevant risk factors have been implicitly excluded. However, if there is some indication of
Welcoming/information phase Is the patient expecting physiotherapy to be the treat ment of choice for the problem? Does the patient understand the movement perspective of physiother apists in problem-solving processes? (Chapter 3).
During subjective assessment •
Does it seem that there is a discrepancy between the pain and perceived disability, especially in combi nation with extreme guarding of movements, non verbal expression and the use of emotive words?
Principles of assessment
•
Does the pain and disability seem to last much longer than an average healing process would be expected to take?
•
Does the patient express a loss of control over wellbeing? Does the patient show excessive rest periods or high intake of medication to influence the pain? Has the patient reduced the level of activities and restricted social participation due to the problem?
•
Does the patient expect the pain to improve before they will consider an increase in activities? In such cases it may be essential to define treatment goals on levels of activity next to objectives to control the pain.
It may be decided to incorporate a psychosocial assess ment in a first session, as it has been shown tha t within 2-4 weeks after an acute nociceptive episode, cogni tive, affective and social factors increasingly start to contribute to the patient's pain experience (Vlaeyen & Linton 2000).
Retrospective and prospective assessments These assessments are essential in the process, as it has been shown that phYSiotherapists may recognize the need for a multidimensional approach to treatment (at the latest after three or four sessions) if progress does not take place as expected in the short-term prognosis (Hengeveld 2000). This is especially so if the expected improvement in activity and participation does not seem to take place, despite the therapist's expectation that the healing and nociceptive processes would allow for this increase in activity (Appendix 2).
Main aspects for physiotherapy regarding psychosocial assessment and management from a b iopsychosocial approach Overall, it may be concluded that within a biopsycho social approach to treatment, it is important to know what patients think, know and feel about their problem, and what influence there is both on and from the social environment. Some elements may be particularly rele vant to follow up in the examination procedures.
Planning phase of physical examination It is essential to summarize the main findings of the sub jective examination and the agreed goals of treatment so far. The patient needs to be informed about the purpose of the physical examination and of the various tests (to serve as a parameter for reassessment procedures).
During physical examination procedures This aspect includes information about procedures and findings and guiding the patient in the perception of the findings (see also communication examples in Chapter 3). With some patients it is essential not only to focus on the abnormalities, but also to explain to the patient which test movements are normal.
Reassessments Announce them, guide the patients to their own percep tions of change and undertake cognitive reinforcement (see Cognitive-behavioural perspective to reassessment procedures above).
Perceived disability This question may be asked at the beginning when establishing the patient's 'main problem'. If a person expresses a high perceived disability in daily life, as shown through non-verbal behaviour and selection of words, a multidimensional approach to treatment may be necessary and the physiotherapist may decide to integrate a psychosocial assessment and a careful process of collaborative goal setting in the first subject ive examination.
Beliefs and expectations about movement and physiotherapy •
•
•
• •
Information and educational strategies These strategies need to be incorporated into the process of collaborative goal setting and reassessment. The patient needs to be given time to ask questions and seek clarification.
•
Is the patient expecting that the specific movement framework of contemporary physiotherapy practice is the treatment of choice for the problem? Which explanations does the patient have on the causes of the problem? Does the patient think the problem has been investigated profoundly enough? Does the patient expect other forms of treatment? Does the patient believe that hurt equals harm, therefore no exercise, activities or work can be performed as long as it is painful? Which associations does the patient have with regard to the biomedical diagnosis of the problem? (e.g. osteoarthritis can only be treated with a joint replacement).
1 19
1 20
M A ITLA N D ' S P E R I P H E R A L M A N I P U LAT I O N
•
Does the patient have other attributions about the causes and treatment strategies for the problem due to individual cultural values and beliefs?
Behaviour •
•
•
•
Does the patient's movement behaviour seem to be in relation to the nociceptive processes? Is there any indication of fear avoidance behaviour? On the contrary, does it seem that moments of relaxation are missing in the busy life schedule of the patient? Is the patient capable of coping with stress situations?
Trust to move, sense of control and coping strategies •
•
•
Does the patient demonstrate 'trust to move' or to perform certain activities in spite of pain? Does the patient perceive a sense of control over pain and wellbeing in daily life situations? Does the patient seem to express a sense of helplessness or even hopelessness?
Opinions of other health-care workers on the problem
Therapist
'You might consider it positively, if you would allow me to say so. Obviously the direct cure has not been found so far. But one approach of treatment may have brought you a few steps forward, one a bit better than another. If I took you on a boat from Switzerland to Africa, I may bring you over the Rhine, but it may be possible that I could not guide you fully to the point of destination. I might bring you a few steps forward in your problem; how ever, it's up to you to judge if that has been relevant.'
General level of activity/participation Not only questions regarding work are relevant, but also hobbies, social contacts and other interests. Does the patient feel capable of doing all the things in life that have to be done or the patient wishes to do?
Responses of social environment 'How are your employers/ co-workers/ family respond ing to your problem?'
Clarification of treatment objectives and interventions (process of collaborative goal setting)
This relates to Kleinmann's notion (1988) that every professional looks at the problem from a profession-specific perspective and will define the problem according to a profession-specific taxonomy. Patients may have received many different diagnoses and cures for their problem, which may not have brought the desired results. It is essential that the ther apist is aware that the explanations given may con tribute to further confusion of the patient. The following communication example may highlight the relevance of clarification before entering an examin ation procedure:
Many people develop chronic disability attributed to pain based on non-clarified expectations. It is important to set limits to what can be offered in therapy and what may not be achieved in treatment. Some patients ini tially may express a treatment objective to have less pain; however, after some clarifications it appears to be more likely that they wish control over wellbeing with self-management strategies (Chapter 3). If a patient expresses the wish to be treated with passive treatment (e.g. massage), the physiotherapist should ask what the patient expects from the massage:
'Everybody says something different, why don't they find it and do something about it?' 'Since I got this problem, you are now the twentieth doctor or therapist that I've seen over the last 2 years!' 'That means you got a lot of different expla nations from everybody?' 'Yes, sure.' 'How would it be if I were to give you another (twentieth) explanation?' ...!
Q 'What kind of treatment would you expect from us?' A 'Well, my neighbour was treated with massage and mobilizations.' Q 'What would you think your body needs from this?' A 'Well, I think I would be able to relax more and I might get a bit more flexible?' Q 'Yes, then massage and mobilizations are certainly good interventions. Would you agree that we also seek some other interventions, like simple exercises which you can perform yourself to relax and to stay flexible? Then you are not so dependent upon my hands?'
Patient
Patient
Therapist Patient Therapist Patient
Principles of assessment
Attentive listening and careful observation As stated before, attentive listening and careful obser vation may give clues to the world of the individual illness experience and may be followed up by gentle questioning during the appropriate moment of the subjective examination and other phases of the ther apeutic process, for example: •
If a patient responds to the question, 'How is your general health?' reluctantly, blushing: 'Well, the doctor has not said anything', this may be an indi cation of an 'externalized locus of control' with regard to health.
•
If a patient describes an accident of several years ago in much detail, as if happened yesterday, there may be some indication of 'posttraumatic stress disorder', especially if the patient regularly has flashbacks or dreams about the incident (Van der Kolk et al 1996).
•
If a patient's pain increases during the interview or physical examination, it may be useful to observe which movements or positions the patient performs instinctively to relieve the pain. These movement directions may be employed as passive mobiliza tion strategies and self-management interventions.
Additional questions Additional questions may be asked at various stages of the subjective examination or other phases of the therapeutic process, for example: • •
• •
•
•
Have you had time off work in the past with pain? What do you understand is the cause of your pain? (Some patients may have difficulty with this question as they expect the therapist to find this out; therefore it may be asked: Which explanations have you received about why it is hurting or have you some thoughts yourself about it?) What are you expecting will help you? What are you doing to cope with the pain? Or: Is there anything you can do yourself to keep control over the pain? Are you able to perform all the activities in your life in spite of the pain? Do you think the problem was investigated sufficiently before you were sent to me?
•
•
How is your employer responding to your back pain? Your co-workers? Your family? Do you think you will return to work (or hobbies and other social contacts/ roles) - when?
CONCLUSION Working within a biopsychosocial (movement) para digm, which integrates psychosocial assessment into the overall physiotherapy assessment, becomes a sub tle process in which physiotherapists need to consider the effects of their words and actions on the personal illness experience and behaviour of the patient. This framework of practice allows the definition of treatment objectives on cognitive and affective levels next to movement rehabilitation on impairment, activity and participation levels as delineated in the IeF (WHO 2001). For example, phYSiotherapists may include sessions with educational strategies regarding the beneficial effects of movement with degenerative osteoarthritis (Dieppe 1984, 1 998) or the current insights on neurophysiological pain mechanisms in relation to the individual pain experience and behaviour of the patient (Gifford 1998a, Shacklock 1999b, Butler & Moseley 2003). It may be concluded, therefore, that the scope of physiotherapy practice has been widened with the conceptualization of biopsychosocial issues. Symptoms and signs as described in the brick wall analogy in fact should relate to the multidimensional aspects of a pain experience. Over a short period of time after an acute nociceptive onset, cognitive and affective factors may start to play a role in the pain experience (Vlaeyen & Linton 2000) which physiotherapists may address with, for example, conscious reassessment procedures, educational strategies, communication and self-management strategies. Within this context a tendency to 'hands-off' treatment may be observed. However, the essence of (manipulative) physiotherapy as a hands-on profession and the power of therapeutic touch in the reintegrative effects on bodily awareness and sense of self should not be underestimated (Rey 1995, Ledermann 1996, Van Manen 1998). All interventions, be they passive mobilizations, exercises or educational strategies need to be monitored within a process of continuous (re)assessment and reflection, in order to determine collaboratively with the patient if all interventions lead to the desired results.
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1 25
Chapter
6
Principles of examination
THIS CHAPTER INCLUDES: •
Key words for this chapter
•
Glossary of terms for this chapter
•
Proced ures of su bj ective
•
function related) •
•
session and plan ning of follow-up
examination
session(s).
KEY WORDS
plan ning and reflection, physical examin ation.
Irritabi lity - a con struct which determines precautions to examination and treatment proced u res. It is defined as 'a little activity causin g severe pain, discomfort, paraesthesia or n umbness, which takes relatively lon g to su bside' (M aitland et al
2001). I rritability needs t o b e consid ered from various perspectives. On the one hand it d escribes the reported pain sensation, on the other it reports the activity provokin g the symptoms, inclu ding the patient's reaction to it. If the symptoms appear to be due to dominant n ociceptive or peripheral neu rogenic input mechanisms, a direct stimulu s-response relation ship may exist. H owever, central nervous system processin g
Reflection of a first examination
Plan ning of the physical
Subjective examin ation,
GLOSSARY OF TERMS
Physical examin ation - general prin ciples and proced ures
examination (pain related,
and (neurophysiological) output
examination and treatment
mechanisms (Gifford 1998a, B utler
proced ures with active and passive
2000) may contribute to ongoing
movements. This may include
tend erness and sensitivity to touch
pathobiological processes (tissue
or movement, which may d istort
mechanisms such as pathology
the direct stimulus-response
and phases of tissue healing,
relation ship. From a behavioural
n eu rophysiological symptom
perspective the con struct of
mechanisms such as central
irritability may be considered as a
n ervous system mod u lation or
form of avoid ance behaviour, as
peripheral n eu rogenic
the person havin g the pain will
mechanisms), stage and stability of
frequ ently interrupt the activity
the disorder, personal factors such
causing the pain ( H en geveld
2002).
It n eed s to be d etermined if the behaviour is adaptive to acu te
as 'lack of tru st' to move as in cases of 'fear avoid ance behaviou r'.
Physical exa m i nation - related to the
n ociceptive or peripheral
specific manipu lative
n eurogenic processes or if the
physiotherapist's an alysis of
behaviour has become maladaptive
movement d isorders and includes
over time d ue to learn ing processes
active and passive movement
and central n ervous system
testing, mu scle testing, soft tissue
mechanisms.
examination and other tests in
Nature fa ct ors - various factors in
order to reproduce the patient's
the ' n ature' of the disorder may
symptoms and to determine which
determine precautions to
movement impairments contribute
1 26
M A I T L A N D'S P E R I P H E RA L M A N I PU LAT I O N
[ to the overall activity l imitation s
in terrupted and usually can n ot be
and participation restrictions of the
taken up again d ue to the in tensity
patient. Physical examination
of the pain. In contrast to
findings serve as parameters for
irritabil ity the pain may settl e fairly
reassessmen t proced ures to
quickly after stopping the activity.
the patien t's accou n t of the
monitor the effect of therapeutic
Similar to irritability, ' severity' may
disorder and its past history. I t
be con sid ered as a form of
includes in formation o n the kind
avoid ance behaviour. As with the
of disorder, site of symptoms,
in terventions.
Severity - a con struct which
behaviour of symptoms and
needs to be a distinction between
establishment of the level of
proced u res. The activity which
seemingly adaptive or maladaptive
d isability, special questions and
provokes the pain n eeds to be
avoid ance behaviour d ue to
history.
Diagnosis from the specific (movement) perspective of physiotherapists generally expressed in terms of -
impairments of movement components, activity limi tations and resources, and participation restriction. The diagnosis may also encompass elements from the individual illness experience and from other factors contributing to the movement disorder.
Although the categorization of hypotheses in principle may be considered an individual process (Larkin et aI1980), the following hypothesis categories may be made explicit during some critical phases of the physiotherapy process by most manipulative physiotherapists:
• • • •
•
Determination of precautions and contraindications to physiotherapy interventions - this has become even more relevant than before since in an increasing number of countries physiotherapists have assumed the role of 'direct-contact practitioner '.
Treatment plan - determination of short- and long term treatment objectives, and selection of meaning ful interventions in a collaborative process with the patient.
•
Determination of parameters to monitor the results of
•
•
•
Initial preliminary treatment, including first reassess
•
ment of effects.
•
The whole process of examination, assessment and treatment is guided by clinical reasoning processes. Physiotherapists frequently follow a process of hypo thesis generation, testing and pattern recognition while making decisions with regard to physiotherapeutic care (Grant et aI1988).
Sources of symptoms or movement impairments Pathobiological mechanisms Precautions and contraindications Contributing factors Level of disability (impairments, activities, participation - ICF (WHO 2001) Individual illness experience (thoughts, beliefs, feelings, earlier experience, values, meanings, influence on and from social environment) and behavioural factors Management (including objectives of treatment and selection of interventions) PrognOSiS (for further details see Chapter 5).
In order to be able to fulfil successful examination procedures, various elements are required:
treatment. •
the
examination and treatment
•
•
-
subjective examination relates to
con struct of 'irritability' there
W hen starting the physiotherapy process, examination procedures are essential prerequisites to successful treatment and the reassessment of results. As pOinted out in Chapter 5, the general aims of examination procedures are as follows:
•
n ervous system mechanisms.
S ubj ective exam i nation
d etermines precaution s to
INTRODUCTION
•
learn in g processes and central
•
A knowledge base (theoretical, professional craft) which is accessible and well organized (Higgs & Titchen 1995, Higgs & Jones 2000) Interviewing skills (Chapter 3) Clinical skills - observation, manual handling and palpation skills, movement skills Clinical reasoning skills - cognition, continuous critical reflection on thoughts, feelings and decisions as well as the capacity to react adequately to the reflections. This may be expressed in the planning phases of the assessment and therapeutic processes.
Principles of exami nation
Within the examination process complex clinical reasoning takes place, in which additional forms of reasoning other than the above-mentioned processes of hypothesis generation and testing are also employed and different paradigms are followed (Chapter 5). For novices in manipulative physiotherapy fre quently it is helpful to follow a more or less fixed set of procedures which allow for comprehensive data gathering in interviews and physical examination procedures. Regular, consequent planning phases allow for the development of reflective skills. In plan ning, novice physiotherapists should be encouraged to make hypotheses explicit, including the conse quences of these hypotheses for further examination procedures or treatment interventions. This process may enhance the development of clinical patterns in memory. With increasing years of clinical experience it may become easier to relate to more complex forms of clin ical reasoning such as narrative reasoning in combin ation with procedural reasoning. This approach may be needed in more chronic pain states or disabilities in which a multidimensional approach to assessment and treatment is more appropriate (Greenhalgh & Hurwitz 1998, Main & Spanswick 2000). The following algorithm of information, procedures, reflection and planning is suggested for a first session: • • •
•
•
•
Welcoming and information phase Subjective examination Planning - summarizing/reflection and planning of the physical examination Physical examination, including preliminary treatment and reassessment End of session - instructions, recommendations, warnings Reflection of first session and planning of next session(s).
Nevertheless, within the algorithm it is essential to retain a certain degree of flexibility, which should allow the patient to give an account of the individual illness experience and the physiotherapist to explore certain information further in order to enhance deeper under standing of the patient's problem. The procedures of questioning and testing should leave space for 'extra procedural' information, such as key words or non verbal language which may be indicative of the individual illness experience. It is therefore essential to follow procedures in subjective and physical exam inations which give a framework to information gath ering, but the procedures should be flexible enough to adapt the processes to the specific needs of the patient.
WELCOMING AND INFORMATION PHASE
As explained in Chapter 3, the welcoming and informa tion phase is an essential stage in the therapeutic process. On the one hand the physiotherapist may inform the patient about the scope and procedures of the physiotherapy process; on the other hand the phys iotherapist may receive information relating to the beliefs and expectations of the patient, especially if the patient is expecting physiotherapy to be the optimum treatment for the problem. At the same time, the physio therapist enhances the development of a therapeutic relationship in which the therapist may start to get a feel for certain barriers or sensitivities of the patient. This stage may encompass the following steps: • •
• •
•
Introduction and joining First explanation on physiotherapy perspective the physiotherapist will examine movement functions Clarification of expectations of patient Explanation on setting (room, therapist, number of treatment sessions, etc.) Sequence of first session - what will be done and what is involved in the patient's role.
(See also 'Critical phases of the therapeutic process' and 'Verbatim examples', Chapter 3.)
SUBJECTIVE EXAMINATION
The subjective examination relates to the patient's account of the disorder and its past history. As informa tion is sought from the patient's perspective of the prob lem, it is essential that the physiotherapist endeavours to see and record the problem in the patient's terms. It is recommended that physiotherapists follow procedures with open and half-open questions, rather than a list of questions or a questionnaire. The latter frequently are more inflexible and may destroy inde pendent thinking, prevent following up of hypotheses which are generated during the process, and can oblit erate the chance of adapting to the patient's line of thought or giving the patient space to describe his personal experience of the problem. Communication skills play a central role in this process, as there will be individual differences between patients. Some patients are excellent witnesses, whereas others appear unable to understand some questions or have difficulty in answering them simply. Skill in extracting the appropriate information requires care, patience and a critical attitude. Communication is full of pitfalls. The physiotherapist may not word the ques tion in a way that clearly expresses the purpose of the
127
MAITLAND'S PERIPH ERAL MANIPULATION
128
[ question and the patient may give different meanings to the words used by the physiotherapist. To make it easier for the patient, only one question should be asked at a time, and should be pursued, within reason, until the answer is obtained. If the patient gives what seems an incongruous answer to the question, then the fault may lie in the way the question was put. It may be kinder to rephrase or explain the question than to restate it, even if it was so simply put that it may have been the patient's error. (For further information, see Chapter 3.) The subjective examination follows several objectives: •
Determination of the problem of the patient, from the patient's perspective - this includes assessment of the
The experienced physiotherapist may adapt the proced ures to the patient's line of thought with the use of the communication technique of paralleling; however, the inexperienced physiotherapist must have a starf.ng point to encourage clarity and a systematic approach. The following sections discuss the procedures of the subjective examination. Each subsection will describe the following aspects: •
•
•
patient's pain or other symptoms as well as the assessment of (movement) functions. •
•
Defining subjective parameters which serve reassess ment procedures - these parameters include information with regard to pain sensation, activity limitations and participation restrictions, behav ioural aspects such as coping strategies, use of medication and indications of psychosocial factors which may hinder a recovery of full function. Determination of precautions and contraindications to physical examination and treatment procedures. The pain experience and the concomitant disability are indicative of specific precautions to examination pro cedures. Frequently this will be described with the constructs of irritability and severity. Furthermore, hypotheses with regard not only to pathobiological tissue processes and 'red flags', healing stage of tissue and stability and stage of the disorder, but also 'trust to move' may be other decisive factors ('nature of the disorder ') in the determination of precautions to examination and treatment procedures (see Planning of the physical examination, below).
•
Procedures which serve information gathering with regard to tl1e process of physiotherapy diagnosis Communication aspects - if appropriate to the information of the section Clinical reasoning - how the obtained information may aid in the generation and modulation of different hypotheses Summary of the main information of the section.
'Kind' of disorder - the main problem
In order to establish the kind of the disorder from the perspective of the patient the physiotherapist may start with the following question ('Question I'): Q
'As far as you are concerned . . . [pause. . . J . . . what do you feel... [pause .. J is your main problem?' .
The stage of subjective examination will be completed with a reflection and planning phase, before entering the physical examination stage of the first analytical assessment. The subjective examination can be divided into five parts:
The therapist may choose to include within the ques tion 'at this stage' or 'why are you seeking the help of a physiotherapist'. The pauses in the question allow the patient time to realize that the therapist is specif ically interested in the patient's own opinion. Frequently it is very informative to complement the information of the 'first question' with the perceived disability from the perspective of the patient. From this the physiotherapist may learn to relate the information with regard to pain to the level of disability. It may be a first indication of a psychOSOCial risk factor impeding recovery to full function ('yellow flag') if the perceived disability seems somewhat incongruous to the symp toms. However, it cannot be emphasized enough that these are only hypotheses - if they are confirmed, it is only an indication to a more multidimensional approach to physiotherapy treatment, rather than denying a patient phYSiotherapy services. Most patients will answer with pain as their main complaint in the 'first question'; however, there may be many different kinds of disorder as the main reason why the patient is seeking the help of a physiotherapist:
1.
•
•
Generation of multiple hypotheses to be tested during physical examination procedures and treatment interventions. Hypothesis categories as mentioned above are described in more detail in Chapter 5.
2. 3. 4. 5.
'Kind' of disorder - establishing the main problem and perceived disability Site of symptoms - body
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171
[
1 72
MAITLAND'S PER IPH ERAL MAN IPULATION
•
Grade V - a small amplitude high velocity general movement performed usually, but not always, at the end of the available range.
•
Grade loc V - a small amplitude high velocity thrust localized to a single joint movement usually, but not always, at the end of the available range.
•
Grade I is usually performed as a slow smooth oscillatory movement. The key feature of a grade I is that movement takes place within the joint rather than just within the soft tissues underneath the operator's hands. Because grade I mobilization techniques are not used in clinical practice as much as the other grades it becomes very difficult for the clinician to achieve effective consistency in the delivery of such a perceptibly small movement. However, grade I techniques, if applied with care, can have a measurable influence on movement related joint pain.
•
•
Grade II, if performed near the beginning of the available range, will be classified as a grade II-, and if taken deep into the range, yet still not reaching resistance, will be classified as a grade II+. Grade III can also be expressed with plus and minus values. If the movement is carried firmly towards the limit of the available range it is expressed as a grade III + but if it nudges gently into the resistance yet short of the limit of the avail able range, it is expressed as a grade III-.
•
Grade IV can be expressed as IV+ or IV- in the same way as grade III.
•
Grade V movements are really the same as grade IV or IV + with the exception that the grade V manipu lation is performed at such a speed that it renders the patient unable to prevent it.
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The plus and minus values for grades III and IV are a representation of how far into resistance the physiotherapist is prepared to move. They are also somewhat subjective and dependent on the confidence and experience of the clinician in determining the end of the normal average range of passive movement (point B) (Fig. 7.5) or the limit (L) of the disordered range of movement (Fig. 7.6). Therefore B is thickened to take account of the variability in the individual clin ician's perception of the end of range. In the same sense, it could be argued that L and Rl (the point where the clinician first perceives an obvious detectable resistance to movement) should also be thickened to take account of this intertherapist vari ability (Fig. 7.7).
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Figure 7.7 A suggestion that the lines L and Rl to R2 could be thickened like B to represent intertherapist variability.
Therefore grade IV -, III - is a movement which moves into the early part of resistance, grade IV, III is a movement which carries well into resistance and grade IV +, III + moves even further into resistance. Grade IV +++, III +++ is a movement which moves into very strong resistance probably to the end of the range (Fig. 7.8).
Principles and method of mobilization/manipulation techniques
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+ and - values adjusted accordingly to a stiff
range.
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If the normal range of joint movement is limited by stiffness for example, grades I, II, ill and IV are restricted to the available range and the + and - values are adjusted accordingly (Fig. 7.9). Similarly pain may arise from a hypermobile joint that is slightly stiffened. Such a situation alters the position of grade ill and IV movements as shown in Figure 7.10. A common error in interpretation of grades is that grade IV is performed more strongly than a grade ill and therefore further in the range - but this is not the case. Grade IV movements should reach the same point in the range as grade ill movements, the only difference between them is their amplitude (Fig. 7.11). It is also worth remembering that when performing grades of oscillatory passive movement there are two directions to consider. The operator needs to control not only the movement into the range but also the return move ment, thus the use of double-headed arrows to depict the amplitude of the grade. As a corollary to this there is often confusion about the relationship of grades ill
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173
174
MAITLAND'S PERIPHERAL MANIPULATION
and IV to resistance in respect of the return oscillatory movement. It should be made clear that the return movement may or may not travel out of resistance depending on the required amplitude and the available range (Fig. 7.12). Within this concept grades of mobilization/manipulation are classified in terms of their amplitude and their relationship to resistance (which includes stiffness and muscle spasm) rather than pain. Several studies have tried to calibrate grades to force or amount of movement using machines such as force platforms or pressure-sensitive motion detectors (Evans et al 1988, Simmonds et al 1995). Others have tried to determine the intra- and intertherapist reliability of the detection of the onset of resistance to movement (R1) before and after training (Latimer et al1996). In most cases there are no reliable data, although the resistance curve produced by artificially lengthening ligaments corresponds very closely to the resistance curve that clinicians detect when passively moving a joint (Maitland et al 2001). However, it is still the authors' opinion that, because of its perceptible onset and it being the factor which naturaily limits joint movement, resistance to passive movement is still the most consistent and least subjective means of defining grades of passive movement. Grades of movement will remain somewhat subjective and debatable phenomena.
Rhythms of mobilization/ manipulation
Joints can be moved in many different ways from a stationary holding through slow smooth movements, to a staccato type rhythm and manipulation performed at speed. For example, a joint that is very painful will be best treated with grades performed slowly and evenly. A stiff small joint, however, would be better treated with sharp, staccato movements. When an oscillatory movement is used in treatment, the treatment direction of that movement is most commonly performed at a speed that is faster than the retreating movement. For example, if a general wrist extension is the movement to be made painless, and it is extended from the fully flexed position, the following application should be considered: •
It would be quite pointless to perform a flexionextension oscillation at the limit of flexion.
•
It would be equally pointless if the speed of the flexion part of the oscillation equalled that of the extension
•
The requirement of the technique was determined by the examination; extension from full flexion reproduced the patient's symptoms most clearly,
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Principles and method of mobilization/manipulation techniques
1 75
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Figure 7.13 Slow steps of stretching. P, pain; i, increase of pain; t, decrease of pain (e.g. shoulder flexion).
and the technique was planned to provoke a degree of pain. The treatment movement is performed thus: the patient's wrist is slowly taken to the limit of its range of flexion, from which it is then immediately extended through the range, and at a quicker speed, so that the symptoms are reproduced. The slower flexion is then repeated, and so on (Chapter 13). This can be thought of as a release technique and it has a place in mobilization that most practitioners do not appreciate. Some patients have difficulty in relaxing com pletely, even when pain is minimal. They periodically tense their muscles without realizing they do so. If large amplitude treatment movements are hindered by this tensing, treatment movements of broken rhythm and changing amplitude should be employed in an attempt to trick the muscles. Sometimes these move ments need to be performed almost as a flick. When attempting to increase the range of movement by stretching a stiff joint which is painful at the limit, the movement should be applied slowly within the avail able range up to the point when pain becomes a limiting factor (Fig. 7.13). This new position should be held stationary (stationary holding) until the pain subsides, after which a further slow stretch is added (perhaps only one or two degrees) until the pain increases again. When the tolerable limit is reached, the movement is again held until the pain decreases. The procedure is continued in these small steps until the pain does not decrease (Fig. 7.14). Small slow oscillatory movements are then performed just short of this limit. When performing slow smooth oscillatory move ments, the change in direction of the movement should be imperceptible (Fig. 7.15). This particular rhythm is best suited to disorders which cause a lot of pain (usu ally grades I and IT). When performing quicker, sharper, staccato movements the speed into the range should
'i4
A Figure
% Range
:y"
B
7.14 Slow steps of 'holding:
Forward movement Backward movement Timing of movement Figure
7.15 Slow smooth oscillatory movement.
Forward movement Backward movement Timing of movement Figure
7.16
Quicker, sharper, staccato movement.
be quicker than the return movement and varied (Fig. 7.16). Staccato rhythm is best suited to stiff joints and grades III and N. A good way of learning the art of speed and rhythm of mobilization is to practise techniques to different styles, tempos and beats of music and apply the tech nique to the rhythm of music at hand. For instance, con trast the speed and rhythm of technique needed to go along with Vivaldi's Four Seasons or Barbara Streisand singing Memories. Duration of technique
There are no set rules for how long or how many times a technique should be performed. This should be dic tated by the effects that the technique is having on the patient's symptoms and movement signs both during and after its performance. Generally speaking, tech niques which are designed to reduce movement-related pain will be performed for shorter duration (up to 2 minutes, once or twice). Techniques for joint stiffness
176
MAITLAND'S PERIPHERAL MANIPULATION
[ may need to be performed several times for several minutes, with additional time being spent using gentler techniques to help treatment soreness to subside.
value as maintenance treatment for joints with osteoarthritic changes.
Chronic aching •
Under this heading the patients do not have severe pain but have an ache which they feel is greater than they class as acceptable. The range of move ment may not be markedly restricted, but if move ment is stretched the pain will increase. This is an end-oj-range pain without a through-range pain component.
•
In such circumstances end-of-range treatment tech niques are required, i.e. grade IV accessory and physiological stretching movements at the limit of the range.
•
If, using these techniques, there is a satisfactory gain in range but the end-of-range pain has increased or occupies a larger part of the range, an easing-off technique is needed to reduce this treat ment soreness. This technique is a larger amplitude movement in the same direction as the grade IV but performed as a grade ill-, slowly and smoothly, gradually progressing to a painless grade ill. If this can be achieved, there will be no soreness resulting from the treatment.
•
If the patient's circumstances are such that restric tion of range is far more important than pain, the techniques of greatest value are the same small amplitude, end-of-range techniques but the rhythm would be staccato.
Clinical application
There are many factors that influence the choice of technique such as: •
• •
• •
• • •
accessory and physiological movements or combinations of these minimal distraction or compression sagittal, coronal, horizontal planes or longitudinal direction (in any of the planes just mentioned) combining techniques in varying sequences pathology and other factors such as recent injury or chronicity the therapist's experience and skill the nature and frame of reference of the patient the desired effect.
There are also influences on the manner in which the technique is performed such as pain and irritability, chronic aching and muscle spasm.
Pain and irritability •
If the patient has a very irritable disorder and the degree of pain is both constant and severe, the tech nique must obviously be gentle. The aim is to afford the patient relief but at the same time to avoid pain during treatment and avoid any latent reaction or exacerbation.
•
The grade to be used would need to be painless, with as large an amplitude as painless range will permit (grades I and II).
•
•
•
The rhythm would be very smooth oscillations per formed slowly. The speed would be as fast as the disorder will permit while still maintaining pain less oscillations (one or two per second) In the first stages of treatment of very painful joints, the prudent choice is to use accessory movements rather than physiological movements, as it is easier to produce a larger amplitude painlessly and more smoothly. As the symptoms decrease, so the ampli tude and the combination of different accessory movements can be used. If a disorder presents with through-range pain it should be treated with a through-range/large amplitude technique. Intra-articular disorders often present with through-range pain for which large amplitude techniques are often of most value. Likewise large amplitude techniques may be of
Table 7.2 summarizes the grades of movement in various conditions.
Muscle spasm When strong spasm is present to pro tect the area from painful movements or positions, there is only one technique to use: •
•
Move the structure to the point in range when the spasm comes into play (at this point the stretch is sustained without movement). When the pain level lowers, as it will, the stretch can be increased and held again (the range will
Table 7.2
Grades of movement in various conditions
Condition
Grades used
Through-range pain Intra-articular pathology End-of-range pain Treatment soreness
11- to 111+ 11- to III or 111IV to IV+ or IV++ II or 111- to III or 111+ painless
Principles and method of mobilization/manipulation techniques
177
]
•
gradually increase until a certain stage is reached when the spasm will not let go). At this point the stretch should be sustained but interspersed with tiny slow, smooth oscillatory movements. It is at this stage, and only at this stage,
when the technique is truly influencing the disorder. Proprioceptive neuromuscular facilitation (PNF) tech niques such as 'slow reversals', 'reciprocal relaxation' and 'contract-relax' can be used to achieve the same initial results as the stepped passive stretch. However, passive oscillatory stretching is the only technique which can achieve that small extra range that the dis order will allow. When a technique is initially used in treatment, it is commonly employed in an exploratory manner to determine the response of the joint. Hence the treat ment movement is continually modified to meet the demands of the condition. The movements used may vary in depth, gradually moving in deeper and reced ing according to what is felt at different depths. This exploratory technique is an extension of passive move ment examination.
The art and commitment of the technique
Maitland (1991) has very strong views about what he considers to be ' . . . probably the most important part of applying any manual technique'. He considers this to be 'a very personal thing and sometimes it cannot be achieved'. Maitland goes on to explain: 'Question: Have you been to an orchestral concert for piano or flute (and I suppose this applies to other solo artists playing with an orchestra)? If you have, you have seen the extent to which the soloist involves himself with the meaning of the work - with the com poser's emotions when he wrote the music? You may feel that what I am trying to say is non sense and has no place in this book. However, it is absolutely essential to involve ourselves with our patients and their problems in the same sort of man ner. I suppose what I am trying to do is reply to a state ment often made, you can't learn manipulation from books, that is quite false. But you can't learn from books unless you commit your whole self, your whole being, to try to feel what is going on with the technique while you are performing it. Please bear with me as I quote from the conductor Andre Previn. A musical concept of learning from writing and doing
As a conductor your responsibility first and last is to those notes (techniques) as written, wiping from your memory all preconceived notions. What I mean
is that you must forget the day to day circumstances of a composer 's life [author 's life] and how such circumstances might or might not have found expression in the music [text]. A lot of the time it's difficult, but that is what you must at least try to do. More importantly, how accurate are those written notes, those dots and dashes ? Music notation [manipulative texts] can at times be hopelessly vague even when dealing with absolutely fundamental ingredients of music [treatment]. Let's look at those four notes [grades and rhythms] as thelJ appear in the score [text]. The fourth note is marked with a pause over it. Well, how long should that pause be? Is it like this ? . . or is it like this ? .. And it's marked with two F's (jf) - Fortissimo - very loud. Well wait a minute. How loud is loud? How soft is soft? And when a composer like 5travinskrJ [Therapist A] specifies loud, is it the same degree of loudness - or even more important the same qualihJ of attack - as when you play Mozart [Therapist B]? Of course not. 50 how do you as a composer or instrumentalist [physiotherapist] decide that your interpretation of the notes is the only possible correct one? After all no two conductors are alike; no two performers are identical and much more to the point -every time you play a piece you discover new details you haven't noticed before. The truth is that there's never any single or definitive interpretation. Indeed I would go so far as to say that the greater the composer, the more your understanding of it is likely to develop over the years. Think about it for a moment. You can write a letter putting words to paper and while you're writing those letters you understand those words mentally without having to hear them out loud. It's the same with composers who have to learn to put musical notes on a manuscript paper as easily as words of a letter, but everybody works differently and while Beethoven's habit was to jot down his ideas in sketchbooks, Mozart, apparently, resolved every detail in his head before he committed the entire works onto paper, he hardly ever changed so much as a note. What I am trying to say is that when you are trying to improve the quality of a sick joint's movements by a passive movement technique it is necessary to put your self or your mind inside the person or, more accurately, inside the joint area, and to involve yourself emotion ally with what the joint is trying to tell you about how it wants to be moved. I believe that this commitment is the difference between the good physiotherapist and the bad phYSiotherapist.'
17 8
MAI TLAND'S PERIPHERAL MAN IPULATION
[ ADAPTATION OF T ECHNIQU ES TO SUIT THE PATI ENT AND THE TH ERAPIST
Most techniques are performed in positions similar to those used for examination, others have different pos itions for the operator. During examination many move ments are tested a few times each; during treatment one movement is performed at a time in one position and repeated many times. The position in the range may alter, however. Gentler grades of movement sometimes need different starting positions from the stronger grades. As the skill of techniques is learned and the feel of joint movement becomes instinctive, each physiother apist should modify their starting position and that of the patient to suit their own needs and circumstances.
(The size and shape of the patient and the size and shape of the physiotherapist will require these modifications.) Each physiotherapist should modify their point of contact with the patient and method of each technique according to the size and shape of their hands and the size and shape of the part to be embraced. Not all ther apists can use their thumbs, hands and arms and bodies in the same way. Modifications of the technique should be encouraged to account for this and allow the physio therapist to deliver the passive movement techniques in a way that is effective but also suits their circum stances. In this way the technique becomes the brainchild
of ingenuity. Many adaptations of techniques for the areas of the body concerned are highlighted in the Chapters 11-17.
References Clinch, R. 1987. The Effects of Grade II Mobilisation on Range of
Movement in Acutely Sprained Ankles. MTAA Proceedings, Melbourne Evans, D., Trott, P., Pugatschen, A. & Baghurst, P. 1988.
Manual Palpation of Resistance, Parts 1 and 2. IFOMT Proceedings, Cambridge, UK
Latimer, J., Lee, M . & Adams, R. 1996 The effects of training with feedback on physiotherapy students' ability to judge lumbar stiffness. Manual Therapy, 1, 266-270 Lowther, D. A. 1983. The effects of stress on the behaviour of connective tissue. Australian Journal of Physiotherapy, 29, 181 Lowther, D. A. 1985. The effects of compression and tension on the behaviour of connective tissue. In Aspects of
Manipulative Therapy, 2nd edn, ed. E. F. Glasgow et ai, pp 16-22. Melbourne: Churchill Livingstone. Maitland, G. D. 1970. Peripheral Manipulation, 2nd edn. London: Butterworths
Maitland, G. D. 1991. Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann Maitland, G. D. 1992. Neuro/musculoskeletal Examination
and Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G. D., Hengeveld, E., Banks, K. & English, K., eds. 200 1 . Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Sahrmann, S. A. 200 1 . Diagnosis and Treatment of Movement
Impairment Syndromes. St Louis: Mosby Simmonds, M.
J., Kumar, S. & Lechelt, E.
1995. Use of a
spinal model to quantify the forces and motion that occur during therapists' tests of spinal motion. Physical Therapy, 75, 212-222 WHO. 2001. ICF - International Classification of Functioning,
Disability and Health. Geneva: World Health Organization
1 79
Chapter
8
Principles of selection and progression of mobilization I manipulation techniques
THIS CHAPTER INCLUDES: • •
•
•
•
Key words for th is cha pter Glossary of terms for this chapter An introduction to the selection and progression of techniques The basis for selection and progression Options for selection and progression
KEY WORDS Selection, progression, movement-related disorders,
GLOSSARY OF TERMS Adaptive deformity - fau lts in posture which develop over time in response to pain, loss of range of movement, muscle imbalance or other impairment (e.g. overpronating feet as a result of ankle dorsiflexion stiffness following i njury). Algorithm - a logica l process or wel l-reasoned steps which lead to the best possible solution to a problem. Alignment faults - faults in the line of the centre of gravity from the base of support through the body. Ideally the line of the centre of gravity
•
Factors infl uencing the selection and progression process includ i n g : - classification o f joi nt signs cli nical groups 1,2, 3ab, 4 and associated signs the sou rce of the symptoms i ntra-articu lar disorders (including the im portance of adding compression i n exami nation a n d treatment) and periarticu l a r d isorders
- onset and natura l history of the d isorder - pathobiological mecha n isms (diagnosis) - dysfunction and movement i m pairments - preca utions and contra i ndications - contributing factors and barriers to recovery - prognosis.
clinical g roupings, source, history, diagnosis, dysfu nction, precautions,
contraindications, barriers, p rognosis.
should pass in such a way that the body's segments are balanced. Asterisks - the d isci pline of highl ighting the main findings in exami nation and d u ring the cou rse of an episode of care (***) Such fi ndings a re usually the su bjective and physical i m pa irments and activity l i mitations. The asterisks can be assessed and reassessed in order to measure the effectiveness of treatment. Clinical g roups - the classification of patients' symptoms and signs i nto recognizable g roups. Such g roups should respond to a ppropriate
mobilization I manipu lation techniques i n a particular way. Complex regional pain syndromes - a com plex pain dysfunction syndrome of u nknown cause that typica lly affects a single extremity. Often associated with reflex sympathetic dystrophy and the causalgia resulting from nerve injury. Components - the individu a l or i nterrelated movement system i m pa i rments which are i nvolved i n a d isorder. For exa mple, if a patient has a stiff, painfu l shoulder, treatment may need to address components in the shoulder, neck,
.
1 80
MA ITLAND'S PERIP HERAL MANIPULATION
L
thoracic spine and neurodyna mics in order for recovery to be maxim ized. Contrib u ting factors - factors such as age, genetic anomal ies, medical conditions, psychosocial i nfl uences, previous i nj u ry and ergonomics which may affect the course of the disorder's natural history. Such factors may a Iso act as ba rriers to recovery or i nfluence the expected response to treatment using mobil ization / m a n i pu lation. Disorder soreness - an i ncrease i n the patient's symptoms after treatment with mobilization/ m a n i pu lation. Such soreness may last a few moments, hours or a few days. If the patient feels better once the disorder soreness has settled this may be considered a desired effect. This effect is often requ i red to 'kick start' recovery when a disorder is getting no better. Pain inhibition - a 'weakness' in movement due to inhibition of
m uscles ca used by pain. Frequently the weakness resolves in proportion to the resolution of the pain. Protective deform i ty - an abnormal position adopted so as to protect an injured or painful body part from further damage or pain (e.g. hip flexion deformity in response to a very painful hip joint). Quality of movement - good qual ity movement takes place when, for example, a limb moves through its fu l l range, idea l ly alig ned with its neighbou ring body part, and without any sign of weakness, protective or adaptive deform ity. Poor qua lity movement occurs when a limb moves through its ra nge with a l ignment fau lts, weakness, or protective/ adaptive deformity. Stage of the disorder - each disorder has a natural history from its onset to its resol ution or its pathway to chronicity. During this natural history the disorder may go through a variety of
INTRODUCTION
et al
stages, including acute severe, recoveri ng, recurrent and chron ic non-resolving. Weak l ink - a contributing factor to recurrences of disorders. If a patient sustains recurrent injury and it always man ifests as pain or dysfu nction in the sa me place, it may be considered that there is a weak l i n k which is most susceptible to the injuring forces. An exam ple of th is is recurrent shou Ider dislocation in baseball pitchers. Wise action - the use of a l l available contem porary evidence a nd cli nical expertise i n dea l ing with neuro m usculoskeletal disorders and the common sense application of such evidence and experience to the individual patient's disorder. Yel l ow flags - psychosocial risk factors for chron icity (in low back pain) such as attitudes a nd beliefs, behaviours, compensation issues, diag nosis, emotions, fami ly, work.
2001), i.e. conditions which one would expect
to respond well to mobilization/manipulation and The selection and progression of mobilization and
conditions which may be difficult to help and the
manipulation techniques from initial contact with the
reasons why this may be so
patient to the last contact should be: •
•
inclusive, patient driven and based primarily on
wise action
(Butler
2000) drawn from all the clinical
ation, all aspects of treatment techniques and how to progress them should be considered including
based on sound, reliable and detailed assessment
starting positions, directions of passive movement,
and reassessment of the effects of treatment on the
combinations available, grades, speeds, rhythms,
patient's movement-related signs and symptoms •
considered in light of the nature of the condition and the stage in its natural history at which it presents
•
durations and styles •
to performing mobilization techniques should be an
precautions and potential barriers to the natural
option. Specific, functionally demonstrated move ment restrictions or unique sequences of movement injury may demand that the technique performed is
integrated into what are quite often multicompo
ingenious and performed in a manner that is unique
nent, multidimensional movement-related disorders •
realistic in view of factors which may suggest a favourable or unfavourable prognosis (Maitland
considered according to the individual patient's circumstances, i.e. flexible, inventive approaches
influenced by all the potential contributing factors, recovery of the disorder
•
7. In view of
the information available through careful examin
information available and acquired •
based on the principles of mobilization/manipula tion techniques as detailed in Chapter
•
striving above all to achieve their desired effects. If the techniques performed achieve their desired effects
Principles of selection and progression of mobil ization/ manipu lation techniques
(Chapter
2), and as long as the general principles
of selection and progression are considered, there can be no wrong way of performing mobilization/
THE BASIS FOR SELECTION AND PROGRESSION OF MOBILIZATION/MANIPULATION TREATMENT TECHNIQUES
manipulation techniques and the possibilities for selection and progression will be limitless.
Consider the following algorithm: •
Selection and progression
Does the patient have a neuromusculoskeletal disorder?
Selection and progression of mobilization/manipulation techniques for movement-related neuromusculoskeletal
•
Is the disorder movement related?
•
Will mobilization/manipulation fulfil the aims and desired effects of treatment - wholly, partially or
disorders should be placed within the context of the overall management of such disorders of the peripheral regions. In many cases mobilization/manipulation will con stitute the primary intervention, such as for a patient with a stiff, painful knee following several weeks of rel
probably not at all? • •
the overall management of a patient's condition or at
•
arc of shoulder movement may need gentle accessory, pain-modulating, passive movements of the shoulder to complement the functional recovery of the rotator
rant or locking position in order to remove any pain
decide upon the most
If the answer is
yes, what is the source and the cause
contributing factors involved in their production? •
How many components of the disorder need to be treated with mobilization/manipulation techniques and in which order?
•
What options are available in the choice of the technique and the method of performing it?
•
What options are available when deciding how to progress treatment based on careful assessment of
cuff and associated muscles. Later on in recovery, mobilization may be needed using the shoulder quad
no,
of the source of the symptoms and what are the
particular stages in recovery. For instance a patient with acute supraspinatus tendonitis and a very painful
If the answer is
appropriate course of action.
ative immobility after a femoral fracture. In other cases mobilization/manipulation may be needed as part of
Is mobilization/manipulation indicated? Yes or No?
the effects of the previous treatment? •
What factors will influence the selection and progression of treatment?
inhibition of the supraspinatus which may be holding back the return of normal quality and balance of shoul der movements.
Does the patient have a neuromusculoskeletal disorder?
Passive movement is not a panacea for all neuromusculoskeletal disorders
patterns of presentation of neuromusculoskeletal dis
The use of mobilization/manipulation should be con
orders and the ways in which they may respond to
sidered in conjunction with other forms of physiother apy and vice versa. Having said this, passive movement in the assessment, examination and treatment of neuro musculoskeletal disorders has a much more valuable and important role to play than is still generally under stood by many therapists. The assessment component is most important no matter what treatment is used, but in this chapter the main emphasis will be placed on the treatment by
Chapter
treatment by mobilization/manipulation. The follow ing questions, therefore, should be asked as part of the selection and progression of treatment: •
Is there a definite, partial or as yet unclassified diagnosis?
•
Is there a recognizable pathology?
•
Is there a reCOgnizable syndrome?
•
Are there any contraindications or precautions to treatment?
passive movement, as applied to the structures and disorders referred to in Chapter
10 outlines the clinical profiles and common
10.
This chapter has been formulated into the context of the actual 'decision-tree' process which most physio therapists use daily when deciding what to do with their patients. Therefore a suitable algorithm has been included as a guide to the likely branches of decision
Is the disorder movement related? What clues from the C/O and P/E (Chapter 6) suggest this? A check list may include the following: •
Does the patient's main problem suggest that the
•
Are the areas of symptoms on the body chart
symptoms are causing activity
making which are needed to, first of all, select the appro priate mobilization/manipulation treatment techniques and then to progress them logically and effectively.
limitations?
related to structures of the movement system: are
1 81
1 82
M A I T LA N D'S P E R I PH E RAL M A N I PU LATI O N
[ •
they intermittent, deep and described with •
Are the symptoms made worse or made easier by
•
contracted, fibrosed or shortened muscle?
influenced by rest and activity? Is the present and past history of the patient's
•
Are there any
movement impairments to be found on
•
•
Are there any alignment faults, protective visible on observation?
•
Will the technique complement the healing
•
Will the technique kick start the healing process by
process?
Can the patient functionally demonstrate a movement or activity which is restricted because
helping to remove physical or cognitive/emotional
of symptoms? •
barriers to recovery?
Is there a relationship between the patient's ranges of movement, symptom response and quality of
•
Does palpation reveal any relevant changes in the
movement potential? •
tissues of the movement system? •
Are there any abnormal physical findings when
enhance active rehabilitation programmes? •
spasm)?
Will the technique complement proprioceptive rehabilitation after injury and give input to
the limbs are moved passively (i.e. pain, resistance, •
Will the technique help to retain an optimal functional environment to attain maximization of
movement? •
Will the technique create an ideal environment for healing?
deformities, adaptive deformities or asymmetries •
Has the technique a role to play in the management of sports injuries and trauma?
physical examination? •
Should a technique be used which has the effect of relieving pain?
symptoms related to injury or unfamiliar use? •
Is a stretching technique required to retain range, make a normal range more mobile or lengthen
certain movements or positions; are the symptoms •
Does the technique need to stretch a stiff joint to restore range?
movement in mind (pulling, stretching, etc.)?
Can the patient's symptoms be reproduced by
Will the technique help in the process of reconditioning movement after chronic disuse?
passive movement testing?
Is mobilization/manipulation indicated? Aims of mobilization/manipulation techniques Will mobilization/manipulation treatment techniques fulfil the aims and desired effects of treatment wholly,
If the answer is •
partially or probably not at all? A checklist for such
patient's condition needs treatment which falls outside of the scope of physiotherapy practice the
•
Should the technique provoke or avoid provoking
•
Will the patient tolerate some exacerbation of the
patient should be referred on to the appropriate practitioner.
the patient's symptoms? symptoms if this is required to promote recovery? Will the technique change the pain, resistance and/or spasm and therefore the nature of the patient's complaint? •
structures normal again or contribute to this process?
•
A check list for the desired effects of mobilization/
2) may
include: Is a technique needed which will restore structures
What is the source of the symptoms and signs (which joint or vertebral segmental level)?
•
What is the cause of the source of the symptoms and signs (joints above and below, vertebral segments above and below)?
•
What are the contributing factors involved with
How many components of the disorder need to be treated with mobilization /manipulation techniques and in which order? •
Will one technique or several techniques be
•
Will accessory movements be needed before
required? physiological movements or vice-versa?
(within a joint) to their normal position or pain free status so as to recover a full-range painless movement?
yes decide:
the disorder?
Desired effects of mobilization/manipulation treatment techniques
•
If the answer is
Will the technique eventually make the abnormal
manipulation treatment techniques (Chapter
which other physiotherapeutic approaches will achieve the desired effects of treatment. If the
aims may include:
•
no decide:
•
Will the spinal component need treating before the peripheral component or vice-versa?
Principles of selection and progression of mobilizationj manipu lation tech niques
•
Will the joint signs need dealing with before or after the neurodynamic signs or the muscle length/strength changes?
What options are available in the choice of technique and the method of performing it? •
•
•
•
•
•
Physiological or accessory movement (shaft rotation). Combined physiological, combined accessory, combined physiological with accessory. Any passive movement with compression or distraction. The starting position of the patient in order to achieve the desired effects of treatment. The starting position of the physiotherapist in order to achieve the best localization and application of forces. The grade (small amplitude, large amplitude, early in range, within range, late in range, short of resistance, into resistance and 'bite'), speed, rhythm (smooth, staccato, sustained), the desired effects (short of discomfort, into discomfort, into pain, respecting pain, into 'bite') and duration of the technique.
physiological movement, passive shaft rotation of a joint is a direction of movement category that fits neatly into the same treatment category as accessory movements of the grade I and II types (Fig. 8.3). Spin or rotation within joints such as the hip and shoulder, however, is accompanied by flexion and extension of the long bones rather than rotation of the shaft. A fuller description of such movement relationships is extremely well described in the arthrology section of Gray's Anatomy (Williams & Warwick 1980). Therefore roll, spine and slide if produced separately are accessory movements. They are not the only acces sory movements, however, others being distraction, compression and gliding or translation. The gliding movements (or translations) may be coronal (medial or lateral) or sagittal (anteroposterior or posteroanterior).
Rotation arm (shaft rotation) Sli de =
Figure 8.2
Passive movements at the glenohumera l joint.
Passive movements The two basic movements available for treatment are physiologicaL movements (which are movements actively used in the many functions of the neuromusculoskel etal system) and accessory movements (which are those roll, spin, slide and gliding or translation movements which a person cannot - usually - perform actively in isolation). Distraction and compression can also be considered as accessory movements (Figs 8.1-8.4). Rotation about long or short bones can often be consid ered as shaft rotation, especially when thinking about the hip or shoulder. This will produce roll and slide between the synovial joint surfaces and often has simi lar effects to other gliding and translatory movements in the treatment of very painful, movement-related joint disorders. Consequently, although technically a
Passive movements
AND
Figure 8.3 Modification of basic movements for passive movement treatment.
I Passive movements
I
I Physiological movements
I
I
Com bined physiolo gical movements
Figure 8.1 treatment.
Basic movements available for passive movement
Figure 8.4 treatment.
I
I I
I Accessory movements (including shaft rotation)
I
Com bined physiological with accessory movements
I
I
I 4.5 Com bined accessory movements
Movements available for passive movement
1 83
1 84
M A I TLAN D'S P E R I P H E RAL M A N I P U LAT I O N
Obviously they may be angulated, including angulations in the cephalad and caudad directions. The physiological functional movements of flexion, extension, abduction, adduction, horizontal adduction (flexion), horizontal extension, medial and lateral rota tion incorporate varying degrees of accessory move ments to allow the physiological movements to occur. They also incorporate varying degrees of other direc tions of physiological movement. For example, a man rarely raises his arm overhead in a pure sagittal plane in daily activities. Combined movements, therefore, inevitably occur in functional activity (Fig. 8.4). The relevance of this lies both in examination and consequently in passive movement treatment. In examination, when active movements are assessed, a patient may be asked to perform different movements in unusual combin ations so as to determine any abnormalities in these movements, including the reproduction of pain. As an example, a patient may be asked to abduct or flex the arms, but to do so, not as a normal free functional movement, but with the arms in medial rotation: the symptomatic arm is compared with the normal or non symptomatic arm. These same combinations of movement can be used as passive movements in treatment. In addition to these, a physiological and an accessory movement can be combined. The combinations can be in the biomech anical direction or even in the reverse direction if this will achieve the desired effect of the teclmique. For example, using as a treatment, knee extension com bined with an anteroposterior movement applied to the knee to improve knee extension:
Figure 8.5
Extension overpressu re a pplied to the femur.
Figure 8.6
Extension overpressure applied to the tibia.
Starting positions
•
biomechanically the anteroposterior movement would be applied to the femur at the knee accord ing to the concave-convex theory (Williams & Warwick 1980) (Fig. 8.5).
The starting positions for both patient and therapist, in order to achieve the aims and desired effects of treat ment, have been described and discussed in Chapter 7 and should be considered in relation to:
•
non-biomechanically, the anteroposterior movement would be applied to the tibia at the knee. These reverse or non-biomechanical accessory movements should be considered as a routine part of examin ation and as potential treatment techniques, espe cially if these directions improve the knee extension when the biomechanical directions do not (Fig. 8.6).
1. the clinical features of the patient's disorder (pain, spasm, pain and stiffness, stiffness) 2. the functional requirements achieved with the technique 3. the age and build of the patient 4. other relevant physical, psychosocial or medical conditions 5. the space and environment available 6. the specific requirements of the physiotherapist.
The accessory movements themselves can be com bined and used in examination and treatment. As a typical example, anteroposterior movement in a lat erally directed inclination can be applied to the superior margin of the medial border of the tibia. This produces a combination of anteroposterior movement with lat eral movement and medial shaft rotation of the tibia under the femur (the knee may be being supported in any physiological position) (see Fig. 8.4).
In this way the maximization of the localization of forces and application of forces can be achieved.
Grades The available grades with which any of the listed move ments can be performed have already been defined and
Principles of selection and progression of mobil ization! manipulation techn iques
discussed (Chapter 7, see also Appendix 1). Neverthe less it should be realized that these grades can be varied widely. A large amplitude movement can be used in absolutely any part of the full exertion of the range according to the definition of large amplitude grades. For example, if a person with a normal shoulder were to lie supine on a treatment couch, with the shoulder free over the side of the couch, a large amplitude of flexion of the whole shoulder girdle could start from a position of the arm hanging towards the floor and could finish as far beyond the median coronal plane of the patient's head and thorax as is physically available (Fig. 8.7). This would be recorded as a maximum range of grade III movement, assuming that the movement carried into resistance. This movement could be depicted by the symbol III. The same applies, in terms of large amplitudes, to combined movements and accessory movements. On a similar basis, small amplitude movements can be performed anywhere in the same full exertion of range. The only point is that if it is performed at or near the beginning of the range it would be a grade I and if it were performed into resistance or near the end of the range it would be a grade IV. If the amplitude was still small but performed in the middle of the resistance-free range (such as might be the case when treating a painful arc of movement), the grade can be classified as small grade II or small grade II- if it is in the first part of the resistance-free range or small grade II + if performed in the latter part of the resistance-free range (Fig. 8.8).
Figure 8.7
Maximum grade III Maxim u m grade III.
II
IV or IV+
1--
Figure 8.8 Shoulder F , grades 1--, 11-, 11+, II, III, IV or IV+: III and II depict large amplitude; I, II, (III) and IV depict the most com mon am plitude; g rade III and II would be the way to depict smaller a mplitudes, as would I and IV, whilst I and IV would also depict large amplitudes but smaller than g rades III(IV) or 11(1).
Rhythms of mobilization Many different rhythms are used in passive movement treatment: •
•
Movements can be performed at a very low speed, so smoothly that there is no one single point when the direction can be perceived as changing from one to another. A movement may be held (sustained) at one point for as long as 5 seconds waiting for pain or muscle spasm to subside before reversing the direction minimally.
•
At the other extreme are staccato rhythms which are sharp, more abrupt movements.
•
Available rhythms can be changed from one to another during the performance of a single tech nique, as can grades. For example, a slow smooth rhythm of grade III may be interspersed with one or two staccato movements still in the same grade III range. Conversely, a sustained grade IV stretching
Fig u re 8.9
Rhythms of treatment movement.
movement may be interspersed with smooth grade III- movements to ease off the soreness resulting from the stretching. This grade III- movement could then be progressed in a very controlled and assessed way to a grade III movement (Fig. 8.9).
Options for progressing treatment In conSidering what options are available when decid ing how to progress treatment on the basis of careful assessment of the effects of the previous treatment, the steps to be taken in progressing a treatment technique
1 85
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M A I TLA N D 'S P E R I P H E RA L M A N I P U LATI O N
are driven primarily b y the symptomatic response felt by the patient during the performance of the technique and the effects of the treatment over the following day or so. Detailed and repeated
assessment,
therefore, is
the demand of this concept (Chapter 5). During the ini tial examination it is important to establish how the patient is affected by the disorder or how the disorder is perceived to be affecting daily life. Accurate, consis tent C/O and
P /E asterisks must be established so that
assessment and reassessment can be meaningful. Examples of measurable asterisks may include: •
(C/O) - a geographical area of symptoms on the
Once all the factors have been considered the physio therapist should have enough information in order to: •
•
• •
•
•
(Appendix 1).
multicomponent approach to the management of
The hypothesis categories are classified as: •
the clinical evidence (signs and symptoms) includ ing the classification of disorders or components of disorders into clinical groupings to form a basis for technique selection
•
repeat the technique
•
alter a component(s) of the technique
•
add in new techniques (same source)
•
impairments,
disabilities
(dysfunction),
activity
limitations •
•
change the technique (same source)
•
choose a technique for a different source or the cause of the source manipulate rather than mobilize
•
add in automobilizations to maintain progress
the structures being treated (the source/ cause of the source)
•
•
the onset, injuring movement and stage in the natu ral history of the disorder
with treatment
•
the diagnosis and pathobiological mechanisms involved with the disorder including the pathology,
have a planned break from treatment followed by a retrospective assessment (Chapter
integrate the use of mobilization/manipulation
movement-related disorders and dysfunction.
should include:
•
confirm the prognosis through progressive,
techniques into a multidimensional,
Options for the progression of the treatment technique
•
have strategies available to deal with barriers to
retrospective and final analytical assessment •
ticular functional movement, a mechanosensitive a limb, an isometric test, a movement diagram
plan stages of progression based on influencing
progression of treatment
(P /E) - a protective deformity, a limitation in a par neurodynamic test, an area of reduced sensation in
record the procedure in a logical, methodical way factors
ring regularly at a particular time of day •
assess whether those desired effects are being achieved
body chart or its quality, depth or consistency; an activity limited by symptoms or symptoms occur
select the technique and method best suited to achieving the desired effects of treatment
the mechanisms of symptom production, the nature
5)
of the disorder and the person and the recognizable
stop treatment.
clinical syndromes •
Selection and progression of treatment using passive movement techniques
and serve as physical or non-physical barriers to recovery
In considering which factors influence the selection of and the progression of treatment using passive
the contributing factors and precautions to treatment which may influence the expectations for recovery
•
the prognosis - the expected rate of recovery and
(2000) have
the classification of neuromusculoskeletal disorders
established comprehensive and flexible hypothesis
into those which are likely to be easy to help and
categories which underpin the clinical reasoning
those which may be difficult to help.
movement techniques, Higgs and Jones
processes necessary for effective phYSiotherapeutic management of neuromusculoskeletal disorders. These hypothesis categories form part of the 'brick wall' mode of thinking as discussed in Chapter 1. When selecting and progressing mobilization techniques, each hypoth esis category should be con�idered for each patient and, within each hypothesis category, the potential role to be played by mobilization or manipulation should be considered.
The primacy of clinical evidence (signs and symptoms, clinical groupings) Irrespective of the diagnosis, the clinical information and evidence
(symptoms and signs)
should be the over
riding factor within this concept which influences: 1.
the choice of mobilization/manipulation as a treatment option
Princi ples of selection and progression of mobil ization /manipulation techn iques
2. the kind of technique used (i.e. direction, starting positions, localization of forces) 3. the style of the technique (Le. grade, speed, rhythm).
The fundamental requirement of the technique there after is that it achieves its desired effects. End-of-range symptoms are treated by different techniques (EaR techniques) than through-range-symptoms (through range techniques) or constant pain (accessory move ments in neutral physiological positions). Mild aching symptoms felt when lying on an aching joint require special techniques (under compression) as do stiff peri articular structures preventing normal function because of pain as well as stiffness (stretching techniques into stiffness to the point of provoking the pain, i.e. into 'bite'). Therefore treatment can be directed towards relief of pain, improvement of stiff functional range or reduction of protective involuntary muscle spasm. Attempts to relate treatment to pathology, there fore, can lead to considerable misunderstanding.
Instead it is better to try to formulate the different combin ations of symptoms into groups and classiJtJ treatment selec tion and progression according to each group. Although the pathology may influence the rate of progression and the prognosis, it rarely influences the type of pas sive movement technique chosen as treatment. Under these circumstances the technique used will be guided by the abnormalities of the joint movement. The three primary physical or movement-related joint signs found on examination of an impaired syn ovial joint and its supporting structures consist of pain, at rest or with movement, stiffness due to contracted structures or adhesions and muscle spasm which is invol untary and protective. Other clinical features such as voluntary holding, pain inhibition and crepitus should also be considered as joint signs. These joint signs can occur separately or in a number of combinations. This classification of movement-related joint disorders into clinical rather than diagnostic groupings enables the physiotherapist to: •
• •
•
•
•
address the patient's main concerns, i.e. address primarily the clinical features of the patient's disorder address the joint signs separately or in combination classify the clinical features in terms of their relationship to each other with movement select techniques related to clinical features rather than diagnostic labels progress treatment in relation to the effects on the clinical features or joint signs recognize patterns of combinations of joint signs and predict their response to mobilization/ manipulation
•
•
assess and reassess the effects of treatment on these clinical features with the help of clinical tools such as movement diagrams (Appendix 1) make a judgement of the predicted response to treatment based on how easy or how difficult it will be to help certain clinical features.
CLASSIFICATION OF JOINT SIGNS (CLINICAL GROUPINGS) Patients with different and often readily recognizable combinations of signs and symptoms can be divided into four main clinical groupings for the purpose of selection and progression of mobilization/manipulation techniques (Figs 8.10, 8.11). These groupings are defined, on the one hand, in terms of the movement-related signs which limit a par ticular range of movement and on the other hand by the relationship within a range of movement between these signs. Each grouping and associated groups can be defined, described, and classified in terms of move ment diagrams. Furthermore, guidelines for selection, progression and final expectation for outcome can be described based on each grouping.
Groups
Figure 8. 1 0
Subdivision of patient groupi ngs.
Groups
Figure 8.11 Grouping of patients with intermittent pain associated with particular movements.
1 87
1 88 c::
M A ITLA N D ' S P E R I P H E R A L M A N I P U LATI O N
Definitions
Group 3 (a and b)
Group 1
•
Where pain and joint stiffness are concurrent, the intensity of the pain increasing proportionally as the strength of the resistance increases: 3a, pain domi nant/limiting; 3b, stiffness dominant/limiting.
•
Pain is related to stiffness but these patients vary widely in their presentation. Although the pain and stiffness are related, the pain may be severe and limiting or it may be moderate and non-limiting, each requiring different treatments. Where pain is dominant, initial treatments must be related to pain as in group 1 and not treated with many directions of movement; when stiffness is dominant, initial treatment can correspond to that of group 2.
•
Movement-related joint signs usually occur together
•
• •
•
Where pain is the main consideration, the existing limitation of movement is due entirely to movement-related pain. Pain at rest/early onset/early limiting. The severity, irritability and nature of the pain indicates extreme care is needed in examination and delivery of the treatment technique. Figure 8.12 represents a typical movement diagram for group 1.
Group 2 •
•
•
Where loss of movement is the main impairment and pain is of little consequence. Those patients who have only a minimal intermittent ache if at all (no pain) but who are unable to move the joint because of stiffness. Movement-related joint signs occurring at the end
of the available range. •
Figure 8.13 represents a typical movement diagram for group 2. P2 (severe)
C
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through the available range of movement. •
Figures 8.14 and 8.15 represent typical movement diagrams for group 3a and 3b.
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Figure 8.12
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P, 1.14 R, L Y2 Range (local severe) headof radius
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Cl in ica l group 3a : pain a nd stiffn ess (pa in
Cl inical group 1 : pa in.
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A Figure 8.13
hip
%
0
R, LV, Range
Cl ini cal group 2: stiffn ess.
B Figure 8.15 domina nt).
Principles of selection and progression of mobil ization / manipu l ation tech n iques
not a voluntary, conscious process and the patient is often unable to release it voluntarily (groups 1, 3a).
Group 4 Where pain is intermittent and momentary. Patients with no obvious loss of joint range but who have momentary pain (intermittent, associated with particular movements, certain positions or certain activities). The 'bite' or jab of momentary pain is usually found with examination in combined or sustained combined movements or in functional corners. Figure 8.16 represents a movement diagram for group 4.
• •
•
•
•
there are two other kinds of muscle spasm which need to be men tioned. The first is a neurological muscle spasm caused by an upper motor neurone disorder (i.e. tonal changes/clonus) and the other is the muscle contraction produced and released voluntarily by the patient to prevent movement - voluntary hold ing (groups 2, 3b especially).
Neurological and voLuntary spasms
-
Pain inhibition Associated signs The following categories of signs may also occur, alone or in combinations with the other movement-related joint signs. Some will be associated more closely with certain groupings than others.
Spasm
Crepitus
Painless spasm a joint can be painless during move
•
-
ment because of protection afforded by muscle spasm. The protective mechanisms are, in the main, both complex and a wonder of nature. It is possible for
the degree of muscle spasm to be such that it comes into play before movement becomes painful (groups 1, 3a) (Fig. 8.17).
Pain before spasm - spasm can also come into play as
•
a more obvious protection for the joint because the movement becomes quite painful before the spasm appears (groups 1, 3a, 4) (Fig. 8.18). muscles may contract in a way that differs from the typical protective muscle spasm. It is a 'holding' rather than an obvious contraction and it affects more of the muscles around the joint. It is
•
'Pain inhibition' is a factor that may be present. It con fuses the presentation of the disorder and so confuses treatment decisions. It can be responsible for apparent (not 'actual') muscle weakness, instability or limitation of range of movement. Painful arcs of shoulder move ment are prime examples of this.
Holding spasm
-
R2 (IV+++) D
C
Crepitus is another subjective element which is evident as a 'through-range' phenomenon. It may be accompan ied by discomfort, and may, or may not, be apparent to the therapist (joint crepitus or tenosynovitis).
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Fi gure 8.17
Pai n less spasm.
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I � :0
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% R 1 P1 L B Y2 (Ioc 'bite') IN E +>---< DO t Range Clinical group 4: momentary pain.
V.
1 st CMC joint
Figure 8.16
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A P1
(local) Figure 8.18
I
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8 1 LV.
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Range
Pain before spasm.
I %
B
1 89
1 90
M A I T LA N D'S P E R I P H E RA L M A N I P U LAT I O N
[ GUIDELINES FOR SELECTION AND PROGRESSION O F TREATMENT
Group 1 : description, initial treatment, desired effects, progression, example of movement diagram (Fig. 8. 1 9, also see Fig. 8. 1 2) Description: clinical situations which fall in to group 1 Pain is severe, irritable and can be at rest, early onset and early limiting (in such cases the importance of attention to detail in establishing the exact onset of PI or the point of increase in pain at rest can not be over emphasized) (Figs 8.20, 8.21). Patients may have severe pain at rest but with care ful positioning the pain can be abolished. This type of pain may be due to inflammation linked to a mechan ical or movement-related cause and should respond well to appropriately performed mobilization (patients who have pain at rest and no amount of positioning of the joint will change the pain are likely to have a non-mechanical/non-movement-related inflammation or some other source of pain-producing mechanism). A joint may be very painful on movement (early onset, early limiting) and when the movement is stopped the pain may continue as an ache of variable intensity lasting varying lengths of time (5 minutes to 1 hour). A joint may be painful at rest but if it is moved by the therapist the pain increases rapidly in intensity to the extent where the therapist is not prepared to move the joint further. The amount of limitation of movement due to pain may be very great and this prevents the therapist from knowing whether there is physical
resistance present, perhaps beyond the limit. The ther apist also cannot know whether there would be any muscle spasm if the joint were moved further. In other words it is not possible, because of the intensity of the pain with movement, to know what phYSical factors may be present in the joint movement into the range. The pain always has a high degree of irritability (i.e. the vigour of activity causing the pain, severity of pain so caused and the length of time taken for the increase to return to its usual level). Such factors should be established during the subjective examination (Chapter 6). When asked what activities aggravate the severe shoulder pain of a patient, and by how much and what then relieves the pain and how long it takes to be relieved, the patient may reply, 'If I put my hand too far up my back my shoulder pain is unbearable, I have to then hold my arm still across my chest for 20 minutes or so before I feel better.' Patients in group 1 also frequently experience a painful reaction following a comparatively painless activity. Consider this phenomenon in relation to the movement diagram: the joint can be moved back and forth in that part of the range before PI quite pain lessly, but if too much movement is performed the
P2 (severe)
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t t
Figure 8.20
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%
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PAIN
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Groups
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Figure 8.19
Group 1 .
'" (f)
Y2
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3/1 0 at rest
41
A Point of increase
Figure 8.21
L V.
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Range
Point of increase in pa in at rest.
%
B
Principles of selection and progression of mobil ization / ma n i pu lation techniques
patient will experience an exacerbation later. The more irritable the joint, the smaller is the amount of move ment required to cause this. The fact that oscillatory movements in the painless part of the range can cause an exacerbation at all shows that the point PI in Figure 8.22 is incomplete when considering pain, and indicates how carefully the patient's pain needs to be assessed and the possibility of reaction appreciated. If pain starts much later in the range (particularly if the pain is not severe), there is little likelihood of reaction from pain less treatment movement. The point of emphasis is that even though care is exercised to determine where pain begins in the range, movement in the painless part of the range may cause a painful reaction; therefore care in both assessment and treatment is essential. Irritability is first assessed by questioning the patient: this guides the amount and type of treatment performed initially. When the patient is seen for the sec ond time a clear assessment of the joint irritability can be made based on any exacerbation that has occurred directly related to a known amount of joint movement. However, it is necessary to bear in mind that at the patient's first visit the joint has been moved during examination as well as treatment. An accurate assessment
2. How early in the range the pain begins. 3. The intensity of the pain in the early part of the range (the earlier the pain appears and the more rapidly it increases, the further back from PI the treat ment movement should start and it should also be slower and smoother). If the increase in pain early in the range is moderate and the severe pain occurs later in the range, the treatment movement can be brought closer to the point where pain begins (Figs 8.22, 8.23).
Amplitude of the treatment movement The more irrit able the joint or the earlier in the range the pain starts or the more rapidly the pain increases, the smaller the amplitude the treatment movement should be. Ampl itude and position in range of the treatment move ment A smaller amplitude movement should be used as the treatment movement is brought closer to PI (early onset). If the treatment movement is performed back from PI a larger amplitude can be used (Fig. 8.24).
c
D
P2 (intense)
ofjoint irritabilihj may therefore not be possible untiL the third visit though it may prove to have been accurately assessed at the outset. The point is that it may be neces sary to repeat a chosen treatment movement up to and including the second visit. Changing a chosen treatment too quickly may not be the best thing for the patient.
Selection and progression of initial treatmen t for group 1 •
Gentle techniques are guided almost solely by pain.
•
The therapist must watch the patient's eyes and body movements at all times for signs of a painful response to the treatment movement.
•
Passive movement carried out in the painless part of the range where pain is early onset/early limiting must be preceded by very careful positioning of the joint to be treated. The amplitude, rhythm, speed and number of oscillations of the treatment move ment must also be considered very carefully.
Fi g u re 8.22 Intense pain, early o n se tlearly limiting; sma l l amplitude movement, slow smooth.
c
P2 (intense)
Position in range of the treatment movement The depth of the treatment movement (i.e. how close the move ment approaches the onset of pain) depends on three factors: 1.
The joint irritability established during the subject ive and phYSical examinations (the more irritable the pain the further back from the point of onset of pain the movement should start).
B
% Range
A
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(local) Figure 8.23 Moderate pain, early part of range; larger amplitude movement, slow smooth.
D
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191
1 92
M A I T LA N D'S P E R I P H E R A L M A N I P U LAT I O N
[ R2 (IV+++) 0
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-
A Figure 8.24
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Choice of a mplitude.
In practice the larger the amplitude that can be per formed when treating movement-related joint pain the more effective it will be. However, in very painful, irrit able joints judgement must be exercised because if the amplitude is too large (both in assessment and treatment) it may cause an exacerbation.
Oscillation of the treatment movement When a joint is irritable a small amount of movement will cause less reaction than a large amount. A highly irritable joint should be moved less rather than more and the treat ment time should vary from 30 seconds to 2 minutes. The oscillations should be slow and smooth (Chapter 7). It is better to undertreat initially until irritability is well established. Direction of the treatment movement One of the least painful movements of the joint should be used as the treatment movement. Where findings indicate that treatment movements must be kept away from the early onset and early limit ing pain it is wiser to treat by using an accessonj movement in a pain-free position rather than a physiological move ment. For example, a patient may have painful limita tion of active shoulder flexion in standing to below the horizontal. It is much wiser to use the least painful shoulder accessory movement as treatment with the patient lying down and the arm carefully supported in a pain-free position by the patient's side. This would be preferable to the use of a physiological movement. Passive movements performed in this way can produce pain-free movement with less likelihood of exacerbation (Fig. 8.25). Such treatment should be performed for 30 seconds to 2 minutes followed by detailed reassess ment of the range of shoulder movement in standing to compare with its 'before treatment' status. Given that the patient has been examined, treated and reassessed, short-duration treatment initially should be sufficient, especially if there is a likelihood of exacerbation.
Fig u re 8.25 Pai n-free accessory movement: i GH in neutra l pain-free position.
Desired effects of treatmen t For patients in group 1, treatment in the initial stages aims to lessen pain and to allow a greater range of active movement. When pain is severe it is often diffi cult for patients to appreciate small improvements, and greater care is therefore needed on the examiner's part to discern the changes taking place. Pain may improve in three ways: 1.
It may not start until later in the range (Fig. 8.26).
2. It may start at the same point but not reach maximum intensity until later in the range (Fig. 8.27). 3. The rate of increase in pain in the early part of the range may not be as great (Fig. 8.28). Other desired effects of treatment at this stage may be to: • •
create an ideal environment for healing introduce movement early in cases where active movement is more painful than passive movement.
Progression of treatment movements If the initial treatment movement selected produces improvement or no change, the initial treatment should be repeated because, on the one hand it has produced changes in the pain with movement or the active range, and on the other hand, where no change has occurred, repeating the technique is necessary to fully establish the irritability as discussed earlier. If the initial treatment causes more pain the same treatment should be performed but with a smaller amplitude and further back in the range from Pl'
Pri nciples of selection and progression of mobil ization / ma n i pulation tech n iques
1 93
] P2 (severe)
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( b)
Figure 8.2 8 Change in rate of increase of pain, (a) before, and (b) after treatment.
0
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On day two (second visit), treatment should be based on reassessment of the effects of the initial treatment movement. There should be some improvement in the pain or active range of movement to indicate further repe tition of exactly the same treatment. As the joint does not require examination on the second visit, treatment can be increased if the irritability of the pain has been firmly established. The amount of treatment should be guided by any reaction that might have resulted from the first treatment session. If there is no further improvement using the initial treatment movement, a different move ment should be used and assessed. As the active range of movement becomes greater than 60% of normal, physiological movements can be introduced without fear of too much exacerbation. In
the previous exampLe of limited shouLder flexion, flexion or the quadrant direction may be used. However, until active movement has reached about 75% of normal the treat ment movement should be kept short of the point in the range where pain begins. Further progression can take place as the range of movement nears normal. The flexion or quadrant direc tion can be performed as III- to III + (as in group 3b) until the last parts of the range are recovered with both accessory and physiological grade N (as in group 2).
1 94
M A ITLA N D ' S P E R I P H E R A L M A N I P U LATI O N
[ Examination may also reveal that i t i s movement related pain alone that is preventing an otherwise full range. This pain can be treated using the following movements: •
Accessory movements or shaft rotation while the joint is supported in its neutral pain-free position. These movements should be performed short of producing any discomfort or pain initially and even avoiding an awareness of movement felt in the joint by the patient.
•
Accessory movements in the neutral pain-free posi tion are chosen initially for those patients whose antigravity, often pain-inhibited, movements are limited by pain or discomfort in the first 60% of the joint's normal range.
•
As the condition improves the treatment movement can be used into a controlled amount of pain or dis comfort (movement into 10-20% of pain or discom fort's maximum intensity is probably advisable initially).
•
Large amplitude physiological movements in the later stages of recovery are then used, i.e. when the joint's range of pain-free movement has improved so that pain and discomfort are felt only in the last 40% of the total range.
Assuming that the special passive movement tech niques produce the desired improvement in range, progressive stages of the techniques can be applied. For example, a hip joint has approximately 15-20° of active flexion before limiting discomfort is felt, after which the following steps may be taken. 1.
The hip is placed (if necessary by using pillows etc.) in its pain-free position in approximately the middle of all the joint's ranges. It may be necessary to ask the patient to adopt this position and then for the therapist to carefully adjust the joint position to obtain the most pain-free position. For the hip joint this may well be in side lying with the affected (uppermost) leg supported with pillows. The tech nique used will be the hip accessory movement or shaft rotation which can be performed with the least awareness of pain, discomfort and movement. This may well be medial shaft rotation (Fig. 8.29) which should be performed with as large a pain-free amplitude as possible both slowly and smoothly. While this treatment movement is being performed very gently the therapist must repeatedly ask the patient if any discomfort is felt. If it is, the oscillation should be performed further back in the range and with a smaller amplitude and with a degree of dis traction of the joint surfaces if there is still discomfort.
Figure 8.29
Hip joint: medial rotation in side lying.
Figure 8.30 side lying.
Hip joint: longitudinal movement (-) in
The question must then be asked again. The patient must not feel any movement nor anything resem bling discomfort during the first treatment if it is to have any chance of reducing the pain and improving the active range of movement.
If this accessory movement is repeatedly ineffect ive the second most pain- and discomfort-free accessory movement should be used. For the hip joint this may well be longitudinal movement in the line of the femur (Fig. 8.30). A third choice may be lateral movement (Fig. 8.31) or anteroposterior! posteroanterior movement (Figs 8.32, 8.33). 2. If careful assessment of the second treatment ses sion shows that there has been some lessening of pain and some small improvement in the pain-free range of movement, then the technique described above can be repeated. Progression may be slow, but if improvement has been shown by assessment,
Principles of selection and progression of mobil ization / man ipulation tech niques
Figure 8.31
H ip joint: lateral movement in si de lying.
Figure 8.33
H ip jo int: posteroanterio r moveme nt in s ide lying.
Figure 8.34
H ip jo int: m e dial rotatio n in supine.
Figure 8.32 H ip jo int: a nteroposterior moveme nt in side lying.
the amplitude of the technique can be made larger and it may also move into part of the range that is painful. If the joint movement-related pain and the active range of movement improve, then the acces sory movements or shaft rotation can be made larger and larger, moving further and further into range (Fig. 8.34), even though it may be a little painful, lmtil a stage is reached when full ampli tude grade III movement can be performed. 3. A stage will be reached when grade III + maximum staccato movement can be performed with min imal discomfort and at this stage the patient's active pain-free hip flexion should be at least 60% of total hip flexion. The trea tment movement, if necessary, can be changed to an appropriate physiological movement performed slowly, smoothly, gently and carefully, Witllout pain at first as a grade II - . For the
hip this may well be in the direction of hip flexion and adduction (Fig. 8.35). The amplitude should be as large as possible, but initially it should be pain free.
1 95
1 96
M A ITLA N D ' S P E R I P H E R A L M A N I PU LATI O N
[ 4 . As the pain-free range improves still further, the movement can be taken further into the range and into a controlled degree of discomfort. 5. Gradually the amplitude and speed of the move ment can be increased until a strong grade III + movement can be performed without pain. At this stage the patient should be more or less symptom free (Fig. 8.36). These guidelines on treating painful joints with passive movement techniques can be extended to any joint. However, the point at which to change from vigorous accessory movement in the neutral position to physio logical large amplitude movements short of pain is not often so clear cut. If there is any doubt in the mind of the therapist, it is wise to repeat the accessory move ments a few more times and make them as vigorous as possible. Then the change to physiological movements can be made, with caution initially. On reassessment, if the joint has become more painful or the active range has worsened, the physiotherapist should revert to
Figure 8.35
accessory movements for a few more sessions. Then if the change is again made, it should be a successful transition. These guidelines are associated with movement related joint pain as has been discussed. The progres sion through to full recovery rarely takes place in this classic sense. The physiotherapist should be aware of all the other physical, genetic, environmental and psy chosocial influences, contributing factors and barriers that will influence the rate and extent of the patient's recovery. These factors will need to be addressed if the well-recognized recovery pathway is to be optimized. These factors and their influences on joint pain recov ery will be discussed further later on in this chapter.
Group 2 : description, initial treatment, desired effects, progression, example of movement diagram (Fig. 8.37, a lso see Fig. 8. 1 3) Description: clinical situations which fall into group 2 •
A painless joint which prevents normal activity beca use it is stiff.
•
When the joint is stretched it feels tight, and per haps even a little painful, but the main complaint is one of stiffness, not pain.
•
The patient goes to the doctor because he cannot tuck his shirt into the back of his trousers or comb his hair - he does not go to the doctor because of pain.
•
Pain may be experienced, for example, as a sharp stab or pull when the stiff movements are stretched, but as soon as movement is released the pain goes.
Group 2
H i p joint: flexion / adduction grade 1 1 - .
t t
STIFFNESS
Groups
Group Figure 8.36
Hip joint: flexio n / adduction grade 1 1 1 + .
Figure 8.37
Group 2.
41
Principles of selection and progression of mobil ization! manipulation techniques
Selection and progression of initial treatment for group 2 Painless stiff joints require mobilization at the limit of the existing range in all possible directions until full active and passive ranges of movement are restored. Therefore all physiological movements which are stiff can be used as treatment movements and, more import antly, all of the accessory movements at the limit of each physiologically stiff range are used. For example, if tl1e glenohumeral joint is painlessly stiff, the accessory movements of the head of the humerus in the glenoid cavity (i.e. posteroanterior, anteroposterior, laterally and longitudinally) may be carried out as a stretching proced ure while abduction of the shoulder is held at the limit of its stiff range (Fig. 8.38). The same accessory move ments may be used at the limit of other stiff ranges such as horizontal adduction (flexion), flexion or tl1e combin ation of extension, adduction and medial rotation as in the hand-behind-back position. If too much stretching is given, the structures may become sore; this is natural, but there should not be a painful exacerbation. When joint soreness is produced by too much stretching, large amplitude movements, in the same direction as the treatment and which approach the limit of range more gently, can be extremely useful in reducing this treatment soreness and at the same time continuing to treat the resistance. To intersperse grade III- movements between grade IV movements is an effective way of easing off soreness while stretching into the stiffness. The guidelines for treatment when a painless stiff ness restricts a patient's function are as follows: •
•
Apply small amplitude oscillatory stretching move ments for approximately 2 minutes, gradually attempting to increase the physiological range using grades IV, then IV +, and even IV + + .
•
Then, while holding the joint a t the limit of the range, perform all the accessory movements that are available in this position. These accessory move ments should be small amplitude, strong stretching and oscillatory (Figs 8.39, 8.40).
•
Repeat this procedure, alternating between physio logical and accessory stretching movements at the
Figure 8.39 fu ll flexion.
Glenoh u mera l joint: longitudinal movement in
Choose one of the stiff, functionally limited physio logical movements and take the joint to the limit of its available range (shoulder flexion/quadrant).
Figure 8.38 abduction.
Glenohumeral joint: longitudinal movement in
Figure 8.40 Glenohumeral joint: posteroanterior movement in flexion.
1 97
1 98
MAITLA N D ' S P E R I P H E RA L M A N I P U LATI O N
effective if more emphasis is placed on physiological stretching, even to the extent of omitting the acces sory movements. •
The average time spent passively moving joints that are not excessively painful is approximately 4-5 minutes at a time. Treatment for group 2 patients can be carried out daily or on alternate days if soreness escalates. Treatment can gradually be withdrawn as the home programme of stretching exercises is stepped up.
Desired effects of treatment F i gure 8.41 adduction.
Glenohu mera l joint: hand-behind-back position,
limit of the available range three or four times dur ing the initial treatment session or until the desired effect of gaining more functional range has been achieved. Assessment of progress can be made dur ing each treatment session and from treatment to treatment. •
If treatment soreness is created by this repeated stretching, it can readily be relieved as described earlier, i.e. use the physiological movement which has been used for stretching as a large amplitude move ment short of the stretching range so that little or no pain is felt. This grade ill- movement should be car ried on at least until the patient is no longer experi encing treatment soreness.
•
As the chosen physiological treatment movement improves in range, other functional movements should also improve. However, an all-round gain is not always guaranteed so it is sometimes necessary to change to a different physiological movement (Fig. 8.41) but still follow the same guidelines of stretching the physiological movements and the accessory movements alternately at the limit of the available range.
•
When the patient's joint is markedly restricted in range, it may be necessary to stretch more than one physiological movement and its accompanying accessory movements. However, when possible
opposite movements in sequence should be avoided. Anyone who has treated a stiff frozen shoulder will know that often when the joint is stretched into flexion, the hand-behind-back movement becomes more restricted, then, when the hand-behind-back movement is stretched, the flexion becomes more restricted. In such cases treatment may be more
• •
• •
To stretch a joint which is stiff but not painful. To retain range with repeated minor injury or after an exacerbation of osteoarthritis. To stretch a normal joint to make it more mobile. To restore range to help proprioceptive or general rehabilitation.
Progression of treatment movements There may be a feeling that the joint should be stretched more strongly in an endeavour to separate whatever tight or adhesed structures are restricting range. However, this should not be done unless the patient's doctor agrees that it is necessary and the patient must be fully informed, with written consent being obtained from the patient. This progression falls into the category of manipulation of the conscious patient. Evidence suggests that manipulation (under anaes thetic) may help to improve the recovery from frozen shoulder (Reichmister & Freidman 1999). M a n i pu lation of the conscious patient Manipulation of the conscious patient may be considered: •
after further use of grade IV techniques, coaxing and stretching into stiffness or a degree of protec tive muscle spasm whicl1 may be present (balance the force of the stretching with the degree of pain felt during the technique)
•
after consultation with the referring doctor and the informed consent (written) of the patient, when one of two manipulation techniques can be used: 1. A technique involving a sudden, very small amplitude thrust in the same direction as the stretching technique which reproduces the patient's symptoms. The stretching should go from a grade IV to a IV+. Finally the thrust should be superimposed onto this stretch. This form of manipulation is best applied to the small
Princi ples of selection and progression of mobilization / manipulation tech niques
joints of the hand and foot where range is limited by stiffness and not muscle spasm. 2. A technique involving stiff painless large joints which may also be protected by some degree of muscle spasm. In such cases a controlled, steady stretching should be used rather than a sudden thrust. The patient must be positioned so that he is unable to move and so that the physiotherapist can feel, in detail, what is happening in the joint during the stretching technique. The patient's eyes and hands should be watched closely for an assessment of the amount of pain or dis comfort he might be feeling while the joint is being stretched. Once a tearing is felt the physiotherapist needs to decide instantly whether to push through the tear or whether to ease off the pressure, believing that a stretch at a later date will be possible. The decision to push on or ease off is guided by the amount of pain or discom fort felt by the patient (Is he likely to accept further stretching?) and by the type of tear felt. A 'dry blotting paper' feel, where it is proposed that one thick adhesion has ruptured, is more likely to result in a favourable outcome. Full range will be restored quickly. The manipulation should be followed up by relief of treat ment soreness and strictly adhered to home exercises if the favourable outcome is to be fully achieved. A 'wet blotting paper' feel is when a soft weak rupture is felt through a larger range. In such cases it is better to do little at one stretch. During training, such techniques should be per formed initially under supervision so that the clinician can appreciate the detail needed to find the exact direc tion to perform slow, sustained stretching and experi ence the feel of the adhesions tearing. The technique for this type of manipulation should be carried out as follows: •
Starting position /localization of forces: the patient should be stabilized with the physiotherapist's body and arm, one hand should be supporting and feeling around the joint to be manipulated while the other hand stretches the joint.
•
Application of forces: a grade IV stretching is applied to the joint in the stiffest direction. The stretch is applied gradually until a point is reached when any protective spasm starts to release. It is usual at this point for the abnormal structures to release or for the adhesions to tear and the range becomes full. There may be a sharp snap, an extended tear through a short range or an extended sloppy tearing through
Groups
3a PAIN and STIFFNESS
3b STIFFNESS and PAIN
Group 4 Fi g ure 8.42
I
Group 3 treatment
a larger range. This last response often does not pro duce a good result and the patient needs to exercise conscientiously despite experiencing a degree of pain (Maitland 1978).
Group 3 (a and b) : description. initial treatment. progression. example of movement diagram (Fig. 8.42, also see Figs 8. 1 4, 8. 1 5)
Description: clinical situations which fall into group 3 (a and b) This is the largest group of patients with neuromusculo skeletal disorders referred to physiotherapy. These patients have joints which are both stiff and painful. Patients with both stiff and painful joints are the most challenging to treat. They require the phYSiotherapist to be precise in discerning the behaviour of both the pain and the stiffness and in determining their interrelation ship. Another d1allenge is to determine whether tl1e pain and resistance are in fact associated with each other or whether they are part of separate joint disorders. The physiotherapist should, wherever possible, know the diagnOSiS and underlying pathology. This knowledge is necessary in order to interpret and understand the interrelationship between the pain and resistance. For example, if a patient injures the medial ligament of the knee, when abduction of the tibio femoral joint is assessed passively immediately after the injury the therapist would expect pain of early onset and early limiting (group 1). A week or so later when abduction is tested, pain may still be the limiting factor but this may well correspond proportionally to an increase in resistance (group 3a). After a few more weeks resistance will probably be the limiting factor to the movement with an associated amount of pain (group 3b). Eventually the movement may not be pain ful but just stiff at the end of range (group 2).
1 99
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M A ITLA N D ' S P E R I PH E RAL M A N I P U LATI O N
L A n essential prerequisite is to know whether the
pain is the dominant component (group 3a) (see Fig. 8.14) or whether the loss of range is due to joint stiffness more than pain (group 3b) (see Fig. 8.15). This will influ ence the physiotherapist's evaluation of how quickly or how slowly the joint signs will change with treatment: •
•
Where pain is dominant, in group 3a, the initial treatment and expected response should be similar to those expected for group 1, i.e. gentle techniques in the comfortable part of the painful range in order to lessen the patient's pain and permit a greater active range of movement. As pain improves, the physical resistance may also show signs of improv ing. This occurs more readily where resistance has a soft feel but not where the resistance is harder or has a bone-on-bone feel to it. Physical resistance in group 3a will vary widely in feel and may or may not improve as the pain improves with gentle techniques. If resistance does not improve as the pain lessens the patient then fits more readily into group 3b where pain is less dom inant. With less severe pain, treatment will not cause exacerbation and techniques that aim to improve both active and passive range should be used, simi lar to those used for patients in group 2.
Through detailed examination and reassessment of changes taking place, the physiotherapist can develop an understanding of how different treatment move ments can be effective in any given clinical situation.
R2 (IV+++) P2 (severe)
c
D
�
:::J
ro c
I
� :c
l!! :� I
1,12
i?:·e Q) > Q) (f)
A
Yo
P1
(local) Figure 8.43
%R1
L
3f4
B
Range Domi nance of pain or stiffness u nclear.
c �
:::J
ro
P' (intense)
c
I
� :c
l!! 1,12 :�
I
i?:.� >
Q) (f)
A
B
Range Stiff range, 60% of which is pain free (60% of available range).
Figure 8.44
Selection and progression of initial treatment for group 30 and 3b If the dominance of pain or stiffness is unclear (Fig. 8.43), the treatment movement should be directed towards influencing pain initially rather than trying to increase the range of movement limited by stiffness. When treating pain, the aim is for the active range to increase as the pain recedes. If this is the case the guidelines to follow are exactly those explained for treating pain in patients who fit the group 1 criteria. The exception is that when changing from accessory to physiological treatment movements, this should be considered when the pain-free range has reached 60% of the available stiff range rather than 60% of what would be normal range (Fig. 8.44). Start with an initial treatment to determine what happens to the joint signs and symptoms when pain alone is treated. What is being determined here, and for later use, is the behaviour of the pain and how it may limit the use of any stretching-type techniques. By examination of the patient's joints, the behaviour
of the pain, the most restricted movements and the pain felt when these movements are stretched can be determined. The painful/stiff movements should be correlated with the patient's loss of function, as well as establish ment of whether it is the pain or the stiffness that is limit ing function. The treatment direction chosen should be the one that corresponds to the patient's loss of func tion, i.e. the movement which reproduces the patient's symptoms or has comparable signs (Chapter 6). If stiffness is quite marked, the treatment of pain will only effect a small degree of improvement and will quickly reach a stage where progress, as determined by reassessment, ceases. When this occurs, the treatment of pain should be discontinued and treatment of stiff ness emphasized, as in group 2 but with a slight differ ence. If the patient feels pain with the stiffness (as they almost certainly will), then the physiotherapist must appreciate its extent and its site in order to be alert as to
Principles of selection and progression of mobil ization/ manipu lation tech niq ues
c
R2 (IV+++)
D
� :J
ro c I
� :0
� :� I .i:!' .�
V2
> Q) en
A
V.
Rl V2 Pl
B
(local)
Range Figure 8.45
Grade IV: stretching into some pain / discomfort.
what the patient is being subjected. Pain felt during the movement should be respected. The more easily the pain is reproduced the shorter should be the treatment time and the gentler the technique. When the comparable movement is used as the treat ment movement and where the intention or desired effect is to stretch out the stiffness, a gentle grade N - is preferable, the physiotherapist being alert to changes in the patient's symptoms during the technique. The first treatment, therefore, should be firm but not excessively painful though it must reproduce a degree of the patient's symptom (Fig. 8.45). Also when directing treat ment to resistance, excessive treatment must be avoided and treatment soreness monitored. Initial treatment of resistance should be directed towards one of the stiff but less painful directions. Assessment after 24 hours or so will answer the fol lowing questions: •
•
• •
Is directing treatment at the resistance going to be the most effective approach? Can the treatment movement be taken further into the range without provoking too much pain? Is it necessanj to go deeper into the range? Should another technique be used?
If there is no progress the treatment can be repeated or another movement can be tried, followed by reassess ment. Alternatively, a second technique can be added, followed by reassessment of the effects of using this combination of treatment movements. When further improvement in the joint range stops or slows and pain moderates conSiderably, the treat ment movements should be taken deeper into the range so that a degree of stretch is applied to the resistance (N- to N to N+ to N + + to N + + +). Initially this should be of short duration.
If pain is felt by the patient, very small amplitude oscillatory stretching movements should be used at a fairly constant position in the range. If the pain is less troublesome a larger amplitude can be used and this will lessen the possibility of treatment soreness. If pain is only reproduced with firm pressure then it is firm pressure that must be applied. The joint can be stretched strongly three or more separate times, each stretch lasting 1-2 minutes. Many different movements which are stiff should be used during one treatment ses sion as long as the effects of each technique on the active range are reassessed. Further progression of treatment is then guided by the assessment of treatment effects at the follow-up visits. More than one site of pain arising from different joints or different areas (different components) should be treated separately. This situation often arises in the hand and the foot. Treatment soreness can be relieved by using large amplitude movements in the painful direction but short of pain/soreness. In the same way, pain associated with a joint that needs to be stretched can be relieved by using large amplitude movements in the stretching direction or other physiological directions. Improvement of these patients will occur in one of two ways: either pain and resistance will diminish until a pain-free full range is achieved, or pain recedes and resistance becomes a harder resistance which will only change if treatment is progressed along the lines of group 2 patients, i.e. stiffness alone. This should include the consideration of manipulation if stiffness does not resolve. It goes without saying that active functional stretching should also be an integral part of the rehabili tation process. However, when treating stiffness in group 3b, where pain is still a factor to consider, both physiological and accessory movements should be used but differently from group 2 when there is stiff ness alone: •
Accessory movements at the physiological limit should still be used but the physiological position in which the accessory movements are performed should be decreased in its position in range in rhythm with the increase in the accessory movement.
•
The more intense the pain the greater should be the in-rhythm reduction of the physiological position.
•
As the pain recedes in response to treatment so the physiological position is not reduced in range.
•
This can be progressed, when pain is significantly lower, to performing the accessory movement while simultaneously increasing the physiological range as in group 2.
201
202
M A IT LA N D'S P E R I P H E R A L M A N I PU LATI O N
Clinical example •
Gr P 4
If
Caudad longitudinal accessory movement of the glenohumeral joint in abduction is the treatment of choice.
•
As the longitudinal caudad accessory movement of the head of the humerus in the glenoid cavity is increased, the glenohumeral abduction is reduced by 5-10°.
•
As the caudad longitudinal movement of the head of the humerus is increased, the arm and elbow are taken into abduction in parallel with the accessory movement.
•
As the caudad longitudinal movement of the head of the humerus is increased, the arm and elbow are kept still, thus producing a further increase in glenohumeral abduction at the same time.
Treatment of a stiff and painful joint, if done too strongly or at the wrong time, will be unsuccessful and cause WUlecessary pain and bring the treatment into disrepute. Nevertheless, it is an important skill for the manipulative physiotherapist to master because the effects can often be dramatic. Therefore it is important
Momen ry pain
Groups
Figure 8.46
C
G roup 4.
,-----�I----,-I--�I---,
P' (intensity)
to take the careful steps necessary to ensure that the full
potential
of
manipulative
physiotherapy
D
:
R' (IV-)
is
reached with patients in this clinical group.
I
Group 4: description, initial treatment, progression, example of movement diagram
A
Description: clinical situations which fall into group 4
Figure 8.47
P1(loc)
Selection and progression of initial treatment for group 4 The combined movement which reproduces the patient's pain should be the movement chosen in treat ment. It should be performed as a mixture of grade IV
R1
B
40% of 1 st carpometacarpal EI trapezium
t
(Fig. 8.46, also see Fig. 8.1 6)
A patient may have a sudden jab of pain at the base of the thumb while beginning to lift a kettle. The pain is fleeting and can occur on some occasions but not on others. This is an important group of patients who are often poorly or unsuccessfully treated. Examination must divulge the joint signs which also reproduce the patient's symptoms (usually combined physiological and accessory movements or combined movements with compression). Sometimes it takes two or three sessions to find the relevant joint signs. It is often difficult to decide whether the joint hurts because it is being stretched or whether the joint is actually painful.
I
Treatment of patients with momentary pain.
and ill movements for several minutes (Fig. 8.47). If the treatment is effective the patient will respond quickly and improvement will occur by at least the third visit.
Clinical example A patient may drop things because of a $harp, severe, momentary pain at the base of the thumb when grip ping, say, a dinner plate. The comparable sign in this case may be a posteroanterior movement of the first carpometacarpal joint with the joint held at the limit of extension and the joint surfaces firmly compressed together (Fig. 8.48).
Spasm There are four main type of spasm which can be pre sent as associated joint signs: • •
handling spasm as a response to movement
Principles of selection and progression of mobil ization / manipu lation techniques
c
S2 (IV+) D I
I
I
R' (strength)
I
Y2
P ' (minor intensity)
:z:. "55 >
CD (f)
A
I Y.
I Y2
5° knee extension
I 3f4
A
P1 R 1 S1 B
Muscle spasm, restriction of knee extension and pain
Figure 8.49
Muscle spasm, restriction of knee extension and pain.
Spasm as a response to quick movements at the limit of a mildly aching, stiffjoint Figure 8.48 Posteroanterior movement of the first carpometacarpal joint.
•
•
as a response to quick movements at the limit of a mildly aching, stiff joint as the limiting factor of the available range.
Handling spasm Muscle spasm may be caused unnecessarily during treatment of painful joints, if the painful joint is badly positioned or carelessly held by the physiotherapist or moved unevenly, roughly or without due respect for pain during treatment. To avoid such situations, care ful positioning of the patient, competent handling and well-controlled techniques are essential requirements.
Spasm as a response to movement When muscle spasm occurs as a constant minimum response to movement no attempt should be made to thrust forcibly through the spasm. In treatment the spasm is best influenced by tiny (grade IV) amplitude movements that gently nudge at the muscle spasm, gradually attempting to move further into the range. If there is no inlprovement, nudging movements should be used in an accessory movement that is slightly restricted by spasm. If this is not effective, the opposite movement to the physiological movement most restricted should be used with grade IV movements at the limit of this range. Joints which exhibit this kind of spasm are often slow to respond to treatment and do not readily respond to relaxation techniques either.
Spasm may present in patients witll mildly or inter mittently aching joints. On examination one or more movements may be slightly stiff and painful, such as knee extension (Fig. 8.49). If passive movements are examined at the usual speed, part of the abnormal find ings may be missed. However, if quick, sharp move ments are used at the limlt of the range, slight muscle spasm may be felt as a response to the test movement. When this response occurs, the treatment movement must be performed so that it almost produces this response. The further away the treatment movement is from producing this response, the less likely is the treat ment to be successful.
Spasm as a limiting factor of the available range Muscle spasm (or holding) in group 3 patients may be the factor limlting range. This type of spasm occurs at the limlt of the available range, is very strong and occu pies only a small part of the range. By treating the pain of a stiff/painful joint and assessing its effects, such treatment will give a good indication of the behaviour of the patient's pain and will also show the degree of irritability of the joint disorder. However, when such spasm is the dominant sign that can be found on exam ination of the joint movements, treatment of pain alone is unlikely to help and therefore movement through range to spasm is likely to be more effective, i.e. the joint should be moved through a physiological range up to the point where spasm starts and there perform very small amplitude movements (grade IV) in con junction with active relaxation techniques. Oscillatory movement is not always desirable (because of irritability or latent exacerbation) and con trolled, sustained stretching techniques may be more valuable. This applies to treating painful joints whose
203
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M A ITLA N D 'S P E R I P H E RA L M A N I PU LATI O N
[ range i s limited b y protective spasm (or structural tightness/ adhesions): •
•
•
•
•
The physiological movement which is restricted and painful is the movement to be used. It is taken to the comfortable limit of range and at that point the physiotherapist's grip is adjusted in order to: 1. have a full control of the movement 2. be in the most economical position to sustain the position 3. prevent the patient moving too much and there fore the therapist losing control of the movement. The chosen movement is then moved slowly into resistance with the physiotherapist being prepared to retreat 1° (1 mm) if the patient winces. With skill, experience and concentration this retreat can be timed to occur just before the patient winces (the patient thus recognizes the skill of the operator and gains confidence to allow further progression, irre spective of pain). Eventually the stretch position can be sustained for 1-2 minutes or more which gives the structures or protective spasm more time to become less painful and more compliant. Consequently the movement can be taken a further degree (millimetre) or so and held until the pain, resistance or spasm reduces again. At this stage small oscillatory smooth movements are performed at this range. They are very grad ually increased in amplitude but always reaching the same end position until a 20-30° movement can be performed. This treatment sequence can then be followed up by the patient attempting the same range of stretching actively. If the range of movement does not improve further and if the spasm shows no signs of relaxing, it may be necessary to consider manipulation under anaes thetic. However, it may be preferable for the manipu lation to be carried out on the conscious patient so that the patient can give feedback and information to direct the exact technique to be used. Manipulation under pethidine is a far more preferable choice. How ever, other factors related to the patient's personality may sway the judgement in favour of manipulation under anaesthetic.
Selection of techniques: clinical grouping examples Group •
7
68-year-old retired miner, now runs marathons for a hobby.
• •
•
•
•
•
Jarred his right hip while digging over his allotment. Immediate, severe pain in his hip causing him to limp badly with only partial weight-bearing possible. The following day the hip was very sore, with pain radiating from the groin down tl1e front of the leg, very painful to walk and flexing the hip was severely limited by pain. Has not been able to lie on his right side due to pain; comfortable lying on his left side. Five days after injury NSAlDs have helped but hip is still very painful. Choice of technique would be grade I or II accessory movement of the hip in the pain-free left side lying position.
Group 2 •
•
• •
•
56-year-old cleaner with a now stiff but painless frozen shoulder. Shoulder flexion, abduction and hand-behind-back functionally restricted by stiffness by 20-30°. Complains of functional restriction rather than pain. Choice of technique would be combinations of grade IV to IV + stretching techniques towards the end of range (e.g. quadrant, medial rotation), along with accessory movements stretching at the limit of the physiologically restricted movements. Treatment of corresponding components such as stiffness in the cervicothoracic spine and scapulothoracic regions.
Group 30 •
•
•
•
•
45-year-old ex-professional footballer with degenerative osteoarthrotic changes of his left knee related to medial meniscectomy 20 years ago. Flare-up of knee pain with swelling after a long walk, stiffness into knee extension. Cannot really get knee comfortable but easiest in slightly bent position. Treat with accessory movements in slight flexion initially, then, after increasing pain-free amplitude, progress to small amplitude grade IV- stretching into extension, respecting and monitoring the effects on the behaviour, site and qualities of the pain. Gradually progress into the resistance until grade IV + + + pain-free extension can be achieved.
Group 3b •
20-year-old office worker with a chronically stiff and painful left ankle after a bad sprain playing bad minton 6 months ago.
Principles of selection and progression of mobil ization / ma n i pulation techn iques
•
Ankle feels stiff and painful when walking up slopes, going up stairs or squatting down.
•
Both dorsiflexion and inversion of the ankle are stiff and painful locally across the front of the ankle.
•
•
•
Pai n Accessory neutral without discomfort • Accessory neutral into discomfort • Accessory neutra l into pain • Physiological large amplitude without discomfort • Physiological large amplitude into discomfort • Physiological large amplitude into pain •
Treatment of choice would be AP or PA grade IV small amplitude stretching with the ankle at the limit of dorsiflexion as firmly as the pain allows, ini tially releasing the dorsiflexion a few degrees as the accessory stretch is applied, then, as the pain settles, stretching the accessory movement without releas ing the dorsiflexion and finally stretching the acces sory movement at the same time as increasing the stretch into dorsiflexion.
Stiffness Physio l ogical limit of range • Accessory l imit of physiological range •
Pai n / stiffness As for pain • As for stiffness (modified)
Treatment soreness can be eased using large ampli tude movements in the direction of the stretch (Le. dorsiflexion).
•
Similar or other accessory movement techniques can be applied in the same way with the ankle held in inversion.
•
Group 4 •
A 23-year-old cricketer who often experiences a momentary sharp, severe jab of pain in the back of his elbow when he has to throw a cricket ball from the boundary.
•
Joint signs were found and the exact pain was repro duced when the elbow was held in extension! adduction with pronation to the limit, and then dis traction of both the radius and ulna along the fore arm line was performed as a grade IV + .
•
Box 8 . 1 Recorm.nen4ed the � of pal'"
The symptoms began to resolve quickly after the third treatment which involved stretching into the pain for 2 minutes three or four times each session.
Box 8.1 summarizes the movement techniques used in the treatment of pain and stiffness.
THE SOURCE O F THE SYMPTOMS (CAUSE OF THE SOU RCE) One of the prime objectives for the manipulative physio therapist is to establish the source and the cause of the source (joints or vertebral segments which may be con tributing to the development of a disorder in another joint or vertebral segment) of the patient's symptoms. Chapter 10 reviews neuromusculoskeletal disorders and common or recognizable pain patterns. Such pro filing can be useful in helping to establish where the patient's movement-related symptoms are emanating from and therefore where and how treatment techn iques need to be directed.
Momentary pain Combined physiologica l ! accessory, limit
When considering choice of treatment technique it is worth noting that through qualitative research it is known that some joints respond better to some tech niques than others. And also through quantitative research it is important to be aware of the effects that treatment techniques can have on both the intra- and periarticular structures within a particular joint.
The joint to be treated It is necessary to consider the choice of technique in relation to the joint which is the source of the patient's symptoms because not all joints respond to the same movement in the same way. For example, accessory movements of the small bones in the hand and foot are more valuable than accessory movements in the hip. There are two factors which make one movement a better technique than another: 1.
the ease with which the movement can be performed and controlled by the operator (e.g. shoulder flexion is much easier to control and perform passively than is shoulder abduction)
2. the relationship of the technique to the normal movement of the joint (e.g. longitudinal movement of the head of the humerus is much more a part of normal shoulder movement than is longitudinal movement of the radius at the elbow or wrist). It is also the case that techniques will differ according to the classification afforded to the patient's symptoms and signs. Techniques for groups 1 and 3a would not be
205
206
M A ITLA N D 'S P E R I P H E RA L M A N I P U LATI O N
adequate as treatment for group 2, 3b or 4 . Likewise techniques for group 2 would be ineffective for group 4. The value of each technique used in treatment must be aSSiduously checked throughout the course of treat ment and this is done by checking the symptoms and signs repeatedly throughout. Sometimes it is necessary to perform a technique twice before an adequate assessment of its value can be made. However, this assessment must be clearly made before the technique is discarded or used in combination with another. Table 8.1 lists the joints that are frequently more effectively treated by the indicated movement. This table does not mean that other techniques should not
Table 8 . 1
be used but it may be a useful guide to which tech niques may need to be assessed first.
IN TRA-ART ICULAR AND PERIARTICULAR J OI N TS Synovial joints can be clinically subdivided into intra articular and periarticular (Maitland 1991) (Fig. 8.50). •
Intra-articular structures which may be a source of symptoms consist of adjacent articular cartilage and subchondral bone, the joint space, synovial fluid and synovial membrane (including plicae), the inner
Joints commonly treated
Joint
Group
Most valuable techn iq ues
Least valuable techniques
Glenohumera l
1 , 3a
PAl longitudinal
Abduction
Acromiohu meral
2, 3b, 4
Arm-by-side: neutral pain-free F l O, O/ lock PAl longitudinal in a or limit
Acromioclavicu lar
1 , 3a 2, 3b
PAl longitudi nal in neutral pain-free Longitudinal in elevation F l O, O/ lock
Sternoclavicu lar
3
F l O, AP, longitudinal
Elbow
2, 3, 4
E, E I Ab, E I Ad F, Fl Ab, F I Ad Pronation I supination PA head of radius, olecranon movements
Wrist/hand
1 , 3a 2, 3b
Accessory radiocarpal, i ntercarpal AP/ PA at the physiological limit or combined with compression Radioulnar AP/PA with compression Digit accessory movements
Hip 2, 3, 4 Knee I patella 2, 3, 4
Footl a n kle 2, 3, 4
Temporomandibular
1 , 3, 4
Rotation F/Ad with rotation and compression Tibiofemoral AP or rotation in neutra l Patellofemora l distraction E, E lAb, E I Ad. F, FlAb, F I Ad Rotation in different physiological positions Patella: long itud inal movements with compression Ankle accessory movements AP/ PA in neutral PF, DF, rotation Accessory movements in physiological subtalar rotation, Ab, Ad I ntertarsal AP/ PA Transverse movements Med. / Lat. Longitudinal caudad
Longitudinal
Principles of selection and progression of mobilization/ manipu lation tech n iques
207
J one-third of the joint capsule which has close affinity to the synovium and any other intra-articular struc tures such as menisci. •
Periarticular structures which may also be a source of pain consist of the outer two-thirds of the joint capsule, collateral or supporting ligaments and muscle tendons which cross the joint.
The evidence for intra-articular pathology and pain is clear (Van Wingerden 1995), as is the evidence for peri articular pathology and pain (Hunter 1994). Chapter 10 reviews intra- and periarticular dis orders and how to identify them clinically. This section will review the evidence base behind the use of passive mobilization/manipulation for intra- and periarticular
joint disorders and provide treatment guidelines which will include: •
•
•
the use of painless oscillatory movement to influence signs and symptoms originating from intra- and periarticular structures movements with compression loading to help restore the function of articular cartilage the use of stretching techniques into the bite of pain to affect minimally restricted periarticular structures.
Intra-articular joint structures and function (Fig. 8.51 ) Articular cartilage In synovial joints, the opposing surfaces consist of hyaline cartilage or articular cartilage which, in its nor mal state, is macroscopically white, shiny and firm, while microscopically the superficial layer has an unbroken though rippled appearance. Articular cartilage consists of:
PERIARTICULAR STRUCTURES
Capsule Ligaments Muscles
•
Ground substance or matrix which contains proteo glycan, amino acid chains. These glycosamino glycans (Fig. 8.52) help to enhance the nutrition, diffusion, synthesis and bioelectric events taking place within the articular cartilage. They also con tribute to the tensile strength of articular cartilage in resisting compressive loading. Evidence shows that during periods of immobilization the measurable proteoglycan content of the ground substance is reduced (Lowther 1979). During prolonged compres sive loading the proteoglycan molecules increase in size and increase their negative charge. These events act to produce a greater repellent force to counteract the compression (Van Wingerden 1995). The water content of cartilage accounts for about 75% of its weight (Bland 1983).
•
Collagen fibres, 90-95% of which are type II, adding
Capsule
Synovium
Subcondral bone -�-
Joint space Synovial fluid Meniscus
to the hydrophilic and glycolytic properties of articu lar cartilage, as well as its tensile strength. •
INTRA-ARTICULAR STRUCTURES
Subchondrial bone Articular cartilage Labrum Meniscus Ligaments Fat Synovium Figure 8.50 Cli nical subdivisions of synovial joints. Reproduced by kind permission from A. R. Blake, 2004.
Chondrocytes/chondrobLasts which function to syn thesize articular cartilage. In adults this synthesis takes place mainly anaerobically with the help of synovial fluid diffusion processes.
Articular cartilage is made up of several layers or zones of cells which appear to be consistent with the prime functions of articular cartilage in coating the ends of bones which move and load bear. These functions load distribution and deformation - decrease the loading on subchondral bone, as well as providing the cartilage with tensile strength, durability, low friction coefficient,
208
M AITLA N D ' S P E R I P H E R A L M A N I P U LATI O N
Selection Progression Intra-atricular
Immobilization Stress deprivation
Subchondral Bone C fibre innervation Substance p present Joint surface pain
Figure 8.51
I ntra-articu lar structu re
and function. Synovial membrane Synovial fluid Viscous, elastic, plastic Nutritious properties Hyaluronic acid Polypeptides Phagocytosis Thyxotrophic
Mechanical properties Creep Stress relaxation Load distribution Deformation/Durability Low friction coefficient Permeability
Composition
90-95% Type 2 collagen fibres Ground substance (matrix) Proteoglycans
minimized peak stresses, elasticity, permeability and insensitivity. The cells in the surface layers appear flattened. Along with synOVial fluid this contributes to the low friction coefficient, surface to surface contact, fluid film lubrication and boundary lubrication. The superficial zones of articular cartilage are also semi-permeable which helps lubrication and nutritional transport by diffusion. The superficial zones, therefore, function to reduce surface wear. The transitional zone of cartilage is that region where the shear forces encountered by the surface layers when the joint surfaces glide on one another are transformed into compressive forces. As a consequence, there is a greater distribution of the load-bearing forces over a much greater surface area. The deeper layers of articular cartilage contain cells which act like tightly bound cylindrical bedsprings which have a shock-absorbing role as well as nutrition enhancing permeability. There is also a calcified zone whereby there is a tran sition from soft articular cartilage to stiffer subchondral bone. In this region the cartilage anchors itself to the subchondral bone (Fig. 8.53). The subchondral bone is richly innervated and vascularized and is known to contain pain-producing neuropeptides such as sub stance P (Van Wingerden 1995).
Chondrocytes Chondroblasts
Through trauma, overloading, disease or wear and tear full thickness defects may appear in the articular cartilage of synovial joints (Bland 1983). Allogenic chemicals and inflammatory mediators can then sensi tize the nociceptors in the subchondral bone causing pain. Also, as a consequence of raised intraosseous pressure, there may be arteriole collapse in the sub chondral bone leading to osteonecrosis and pain.
Synovial membrane, synovial fluid and the consequences of pathology Synovial membrane lines the joint capsule, intra articular ligaments, tendons and intracapsular bone. Cells within the membrane function to secrete hyal uronic acid which affects the viscosity of synovial fluid. The cells also function to promote phagocytosis and secrete polypeptides and cartilage-degrading enzymes. Synovial fluid has viscous, elastic, plastic and nutri tious properties. It plays a very important role in the movement of joint surfaces on each other. The proper ties of synovial fluid are complex when considered in relation to the part they play in contributing to the low friction coefficient and nutrition of articular cartilage. With regard to movement of a synovial joint, the coefficient of friction between adjacent joint surfaces has been presented as 1 .002 by Charnley (1973) and
Principles of selection and progression of mobil ization / manipu lation techniques
Chondroitin sulfate
\
(a)
/ Keratan sulfate
� Protein core (b )
-O
� � � � _
H
O
H
OH
NH-CO-CH3
OH
Hyaluronic acid
(e)
� � � � C
-O H
O
H
H
H
OH
O_ H
NH-CO-CH3
Chondroitin-6-sulfate
(d)
COO -
_o
CH2-0H
� � � � 0
0
OSO O
H
H
H
OH
o_ H
NH-CO-CH3
-o :
Chondroitin-4-sulfate
:
( e)
CH OH
_O
O
H
OH
H
CH2- S03 -
0
H
OH
H
0 OH H
0
H
0H
NH-CO-CH3
Keratan sulfate Figu re 8.52 (a) Proteoglycan monomer (left) composed of a protein core with the chondroitin sulfate and keratan sulfate side chains. In collagen type I, fragments (right) of the proteoglycan monomer also exist. (b) Hyaluronic acid; (e) chondroitin-6-sulfate; (d) chondroitin-4-sulfate; (e) keratan sulfate. Reproduced by kind permission from Van Wingerden (1 995) and Scirpo Verlag.
between 1 .013 for normal stresses and 1 .2 for higher than normal stresses by Malcolm et al (1975). The viscosity of synovial fluid is different in differ ent joints and it also varies within a joint when there are changes in the type of movement being performed. Clarke (1975) stated that, as a result of experimental work, the coefficient of friction 'decreased with increased load'. For a normal joint to function properly it is neces sary to have normal articular cartilage and synovial fluid. When these two components are normal and a joint is moved passively, with or without compression, any variations that may occur in the coefficient of fric tion will not be perceptible to an examiner. The following figures show the recently dissected hip joint of a heifer being moved through an arc of approximately 30°. This is performed firstly with the joint surfaces gently opposed (Fig. 8.54) and secondly the same movement is produced while the joint surfaces are firmly compressed together (Fig. 8.55). This is the best possible method of manually and mentally appre ciating precisely just how smooth joint movement is when the surfaces and synovial fluid are normal and, more importantly, how the feeling of the quality of the smoothness is unchanged in the normal joint when compression is added. (The experiment is strongly rec ommended to prove the credibility of the fact.) Mow and Kuei (1975) reported that they analysed the fluid mechanics of the squeeze-film action as a function of the viscoelastic parameters of whole synovial fluid, and hyaluronic acid solutions. The theoretical solution showed that normal whole synovial fluid is important in the protection of cartilage, lowering overall pressure in the fluid and increasing the total loaded area of the joint. The important fact that they determined, which relates directly to this discussion, is stated in their words:
It was concluded that the viscoelastic behaviour of the whole synovial fluid, attributable to the hyaluronic acid protein complex, is important in the analysis of the wear of articular cartilage and that lubrication and wear must be considered as two separate but often interrelated phenomena. Barnett (1956) was able to show that by injecting hyaluronic acid into one ankle joint of rabbits, thereby reducing the viscosity of the synovial fluid, and by subjecting the rabbits to long periods of exercising, the injected joints showed much more severe attrition of the articular surface than the control joints. Broderick et al (1976) have shown that there are chemical differences in the synovial fluid of joints
209
210
M A I T LA N D ' S P E R I P H E RA L M A N I P U LATI O N
Figu re 8.53 Articu lar cartilage zones. Reproduced by kind permission from Van Wingerden (1 995) and Scirpo Verlag
Zone 1 Zone 2 Zone 3 Zone 4
Zone 5
Zone 6 Zone 7
§
1
§
§
',bd-ood" , boo, Bone Vascularization
Fig u re 8.54 Joint movement without compression.
Figure 8.55
J oint
movement with compression.
1 1
Tide mark
.
Pri nciples of selection and progression of mobil ization/ manipu lation tech niq ues
affected by rheumatoid arthritis, osteoarthritis, Reiter's syndrome, pigmented villonodular synovitis and septic arthritis compared with the synovial fluid of a normal joint. With the chemical changes in the synovial fluid that occur with osteoarthritis, there may also be a change in the viscosity of the synovial fluid. Thus, as well as provoking attrition of the articular surfaces, changed viscosity may also increase the coefficient of friction. In Clarke's (1975) experimental work he found that when the joint was 'run dry, the coefficient increased 2 to 10 times'. He also stated that the wear of the carti laginous surfaces in the dry runs 'was evident as fis suring and flaking of the surface layer similar to osteoarthri tic fibrilla tion'. McDevitt and Muir (1 977) carried out an experi ment in which osteoarthritis was induced in the right knee of dogs by sectioning the anterior cruciate liga ment. Six or more weeks after the operations they found that gross changes in the cartilage of the affected joints were evidenced by the surface being 'less shiny and softer and was noticeably thicker than the control cartilage' which was white, shiny and firm. Micro scopic changes were noticeable one week after the operation. 'The cartilage . . . one week after operation, was slightly roughened with occasional small clefts . . . The number and depth of the clefts was greater two weeks after operation . . . Fibrillation . . . gradually pro gressed with time after the operation until, after 7 weeks, deep clefts were evident and by 16 weeks erosion of the articular surfaces was complete' (Fig. 8.56).
Clinical application With changes in the synovial fluid and the superficial layers of the articular cartilage there is an accompany ing change in the coefficient of friction. From the time when changes begin, a stage must be reached when, on physical examination of the joint's movements, the normal feel of friction-free movement is replaced by a perceptively less friction-free feel. This clinical change is more readily appreciated when the joint surfaces are held compressed together and moved. Everyone is familiar with the feel of moving a joint which is devoid of all (or nearly all) its articular cartil age. Similarly, we would all accept that some of these joints have a rougher feel when moved than others. We should, therefore, be able to accept th.e fact that a stage must exist when this change in friction first becomes perceptible on physical examination. It is the early stages in the changes of friction-free movement that can be assessed by passive movement and this assess ment can be appreciated earlier if joint surface com pression is utilized during the test movement. The time
Figure 8.56
(a) Normal cartilage; (b) fibrillated cartilage. Figure 8.56a reproduced with special thanks to Dr Stephen Pang and the Department of Anatomy and Cell Biology at Queen 's U niversity Ontario, Ca nada.
at which this change in friction will be perceptible to any particular examiner will depend on the threshold of force perception.
The healing of articular cartilage •
Evidence is now overwhelming that chondrocytes can and do divide and synthesize the macro molecules of cartilage. Osteoarthritic lesions are reversible according to Bland (1983).
21 1
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M A I T LA N D 'S P E R I P H E R A L M AN I P U LATI O N
•
Articular cartilage i s avascular and is prevented from mounting a vascular response when there is isolated cartilage damage. Healing of articular carti lage is limited by the absence of vessels within the cartilage. Some cartilage defects never heal.
•
Chondrocytes in articular cartilage are capable of cell division. Regeneration of cartilage is slow and occurs most at its margins. However, the rates of syntheSiS in vitro are increased 1 0-20 fold b y mechanical stimulation.
•
Articular cartilage healing after injury depends on the depth of the defect. Healing can occur extrinsi cally. This form of healing is dependent on a synovial reaction or subchondral bone being penetrated at the time of injury. Subchondral capillary injury results in the formation of a fibrin clot which is then replaced by granulation tissue and fibrocartilage. Healing of articular cartilage can also occur intrinsically. This form of healing is dependent on the presence of chondrocytes to synthesize a new matrix. In this case healing is dependent on diffusion of nutrients from synovial fluid. Isolated injury to cartilage which does not extend to subchondral bone heals slowly and incompletely.
Contemporary methods of promoting the healing of articular cartilage are reviewed by Hunziker (2002) who concludes that there are many novel and promis ing biologically based approaches to the enhancement of articular cartilage repair. The vast majority of these approaches are still in the experimental and develop mental stages. The review looks at: •
•
•
•
•
•
spontaneous repair responses in different types of lesions surgical interventions aimed at inducing repair without the use of active biologics surgical interventions drawing on autogenic and allogeneic tissue principles growth-factor-based biological treatments and gene transfer protocols the technical problems associated with repair interventions the role of mechanical factors.
Hunziker acknowledges that the outcome of repair tissue quality in a number of animal experiments is improved by intermittent active or continuous active/ passive motion and that this has been recognized for some time. The conclusion drawn is that ' . . . in human clinical practice, post-operative care and phYSical ther apy will most probably play I}ot inconsiderable roles in determining the healing outcomes' [of the biological based approaches to the enhancement of articular car tilage repair] .
The clinical scientific evidence for the use of exercise, passive mobilization and compression to treat in tra-articular disorders Much of the scientific evidence leading to the under standing of the importance of exercise, passive move ment, and cyclical loading to maintain an ideal functional environment for articular cartilage and to help promote healing of defective cartilage comes from studies on stress deprivation and consequently reversal of stress deprivation, i.e. the effects of immobilization and mobilization on the healing of articular cartilage (van Wingerden 1995). Exercise Lowther ( 1979) concluded that there are metabolic effects of mechanically distorting the cell mem brane of chondrocytes and that there are two differ ent roles of movement, both of which stimulate the cartilage to produce matrix components: diffusion of nutrients into the matrix from the synovial fluid, and chondrocyte membrane deformation similar to that produced during loading of the joint.
•
•
Ekholm (1955) suggested that exercise to the joint appears to increase the penetration of cartilage to nutrients from the synovial fluid.
•
Maroudas et al (1968) proposed that an increased flow of nutrients from the synovial fluid into carti lage is due more to agitation of the fluid film on the cartilage during exercise than to cartilage compres sion and decompression.
•
Lowther (unpublished observation, 1983) referred to this 'agitation' as 'surface stirring', a term which superbly fits the treatment techniques described below.
Passive movement Caterson and Lowther (1978), from their work with sheep, propose that 'alterations in pro teoglycan synthesis and content are the result of nutri tional changes directly related to joint movement and stress'. In other words, cartilage nutrition is maintained by passive movement, without concomitant loading of joint surfaces. The case for the clinical value of adding compression in the treatment of intra-articular dis orders will be explored later in this chapter. Lowther (1983) in an unpublished observation stated that 'one would predict that compression or loading in the joint should be minimized, particularly in the very acute stages of inflammation when the polymorphonu clear cell population in synovial fluid is maximal. When this stage has passed, then load bearing should, on bal ance, be more beneficial than detrimental to recovery of the matrix.' These stages correspond on the one hand to
Principles of selection and progression of mobil ization / manipu lation techniques
the severe restrictive intra-articular disorder and on the
If the work of Salter et al
(1980) is to be believed, the
other hand to those patients who experience minor
relationship between the paffiful osteoarthrotic joints
symptoms on compressive loading.
and the treatment by passive movements may, by
Salter et al (1980) found, when studying the healing of
improving nutrition, have an advantageous effect on
defects in articular cartilage, that an affected joint con
the cartilage (and probably on the associated com
tains a far higher percentage of hyaline cartilage cells
ponents) to the extent that the patient's arthrotic joint
when it is moved passively and continuously (continu
will function better and be less painful.
ous passive motion, CPM) than if the joint is treated
(1991) has proposed that there
by active movement, and far more than if it is treated
Compression
by immobilization. These findings complement the
is sufficient evidence to validate the view that symp
authors' view that controlled passive movement is more
toms may arise from a joint surface disorder and that
Maitland
effective in relieving the pain of intra-articular disorders
there are several clinical circumstances under which
of the osteoarthrotic type than is active movement.
examination of movement of the synovial joint with its
Salter et al
(1975) state that:
surfaces compressed together should be performed. These include:
In order to study the effects of continuous passive motion on the healing of experimental full thickness defects in articular cartilage [they) made a standard experimentaL injury [four full thickness drill hoLes) in the distal joint surface of the femur in twenttj immature rabbits which were then treated by one of three methods: immobilization, normaL cage activity, or continuous passive motion for periods of up to 4 weeks. Healing of the 80 defects was studied closely and histologically. With immobilization, fibrous tissuefilled the defects and there were many joint adhesions. With normal cage activity there was imperfect heaLing by a combination of fibrous tissue and poorLy differentiated cartilage. With continuous passive motion, however, healing through the formation of new hyaline cartiLage (chondroneogenesis) occurred in over half of the defects within 4 weeks. Gebhard et al
(1993) found that in 30 rabbits with
•
when the subjective information suggests the presence of a joint surface disorder
•
when the history indicates that the injuring activity includes joint loading
•
reproducing the patient's symptoms when other test movements have failed to do so
•
when through-range-pain is present and the pain response is greater when compression is added, therefore confirming the presence of joint surface related symptoms
•
assessing any changes in the friction-free feel to joint movement when compression is added
•
determining the most appropriate technique to progress the treatment of a joint surface disorder
•
exploring the most comfortable means of treating a very painful periarticular disorder.
Compression can be applied to any synovial or non
experimentally induced intra-articular injury anything
synovial joint. Many of the techniques are described
less than
16-24 hours of CPM was ineffective in pre venting joint stiffness whereas anything less than 24
elsewhere in this text, such as for the inferior radio
hours CPM was ineffective in reducing joint swelling.
humeral joint (Chapter
Lowther
(1979) goes some way in. challenging the
ulnar joint, the superior radioulnar joint, the radio the ankle (Chapter
12), the hip (Chapter 14) and 16). Compression can also be added
notion as to whether his observations can apply to osteo
easily, with skilled application, to joints such as the
arthrotic joints by summarizing his work as follows:
carpometacarpal, metacarpophalangeal, tarsometatarsal, metatarsophalangeal and interphalangeal joints. It may
Although the cartilage shows degenerative changes, these tend to be focal. Since inflammation of the synovial membrane is not a major feature, the joint capsuLe and Ligaments are not subject to the same enzymatic damage; continued Load-bearing will not affect the capsule and tendons, but may increase the rate of deterioration of the cartilage surface. However, movement of the joint is essential to maintain cartilage nutrition for as long as possible, and to minimize adhesions and bony fusion which tend to increase as the cartilage surface degenerates.
also be necessary on occasion to use functional weight bearing positions in which to apply mobilization tech
8.57), 8.58) or the hip joint (Fig. 8.59).
niques, for example, the tibiofemoral joint (Fig. the ankle joint (Fig.
Compression can be applied further to the gleno humeral joint as follows (Fig. •
Patient starting position:
8.60):
supine lying in the middle
of the plinth with the elbow flexed. •
Therapist starting position: standing by the side of the plinth facing across the patient's body.
213
214
M A I T LA N D ' S P E R I P H E R A L M A N I P U LATI O N
Figure 8.59
Hip compression in side lying.
Figure 8.57 Mobilization of the tibiofemoral joint i n weight bearing position.
Figure 8.58 position.
Mobil ization of the ankle joint in weight-bea ring
Figure 8.60 Glenohu meral movement with compressio n : (a) l o w a n g l e ; (b) h i g h angle.
Principles of selection and progression of mobi l izatio n / ma n ipu lation tech n iq ues
•
•
Localization of forces: the examiner should fully sta bilize the patient's arm against the side with the examiner 's arm. The palm and heel of the exam iner's other hand should be placed around the greater tuberosity of the humerus with the forearm directed at right angles to the glenoid cavity. Application of forces: the examiner then moves slightly so as to abduct and adduct the patient's arm through an arc of 30° from approximately 20° of abduction to 50°. The arc should be oscillated firstly without any pressure being exerted by the examiner's hand against tlle greater tuberosity of the humerus and then repeated with pressure against the tuberosity compressing the head of the humerus into the gle noid cavity (Fig. 8.60a). As the arm is taken further into abduction, ilie compression is effected by the left hand and the righ t thigh pushing from the elbow along the line of the shaft of the humerus, in this case (Fig. 8.60b). The resultant vector of these forces pro duces a compression of the head of the humerus in
the glenoid cavity at right angles to ilie surface of ilie fossa. The smoothness of movement should be com pared, as should ilie pain response in the com pressed and non-compressed situations. Compression can be applied to the patellofemoral joint (Figs 8.61-8.64) as follows: •
Patient starting position: ilie tibiofemoral joint should be positioned in extension and also in different pos itions of flexion. The reason for this is iliat in different
Figure 8.63 Cephalad movement with compression with the knee flexed.
Figure 8.61 Cephalad movement with compression with the knee extended.
Figure 8.62
Caudad movement with compression with the knee extended.
Figure 8.64 Caudad movement with compression with the knee flexed.
21 5
216
M A I T LA N D ' S P E R I P H E R A L M AN I PU LATI O N
L positions o f tibiofemoral flexion the undersurface of the patella will have different points of contact with the femoral condyles. •
Therapist starting position: standing by the side of the couch facing across the patient's body.
•
Localization of forces: one hand should cup around the patella in order to direct the movement. The other hand should be placed so that the heel of the hand is in contact with the margin of the patella at a point relevant to the direction of movement required. When compression is required the hand which is cupped around the patella is used to apply pressure through its anterior surface while the other hand moves the patella. The examiner's elbows should be positioned in line with the movement direction to be performed.
•
He complained of intermittent severe sharp pain brought on by movement, particularly if he knocked his toe, even lightly. Such pain would last for several minutes before subsiding, and even following this interval he was well aware that symptoms were more easily provoked than at other times.
•
He responded well to initial physiotherapy interven tion but then treatment ceased to produce further improvement.
•
On re-examination his normal functional movement ranges were full and comparatively pain free. How ever, when the metatarsophalangeal joint was sta bilized in a position midway between the limits of flexion, extension, abduction, adduction and rotation and the joint surfaces compressed firmly together, his pain could be completely reproduced with small abduction-adduction movements or small rotary movements (Fig. 8.65).
•
These pain-reprodUCing movements were then used as passive movement treatment techniques, initially with a degree of compression sufficient to cause only minimal discomfort. As improvement occurred the techniques were progressed in both vigour and duration.
•
Assessment was made at each visit by asking the patient to stub his toe gently into the palm of the examiner 's hand and monitoring the relationship
Application of forces: the patella should be moved cephalad, caudad, medially, laterally and in a direc tion of axial rotation (especially with the medial bor der of the patella moving anteroposteriorly into the femoral intercondylar area). The findings regarding smoothness of movement and pain response should be compared with the patient's complaint and the normal knee.
•
•
Application in treatment: patellofemoral disorders which are mechanical or degenerative in origin respond well to treatment by passive movement and a degree of compression which permits movement without pain or with only a small amount of discom fort. The technique is performed as described above and the movement is oscillated for 1-2 minutes. Assessment of changes effected is then carried out and the degree of compression used in treatment is based on the assessed response. A stage may be reached where strong compression is used without increase in discomfort. The patient should, by then, notice improvements in both symptoms and function.
The following example is of the later stages of treat ment of a 20-year-old male with a painful right metatarsophalangeal joint of the big toe: •
Three months previously, while playing association football, he kicked the ball while at the same time an opponent blocked the kick.
•
The patient described the injury as a 'stubbed toe' without any flexion or extension involvement.
•
The injury caused severe pain in the metatarso phalangeal joint of the big toe. This pain gradually subsided over the following month but then remained unchanged.
Figure 8.65
Physiological movements with compression.
Principles of selection and progression of mobi l ization ! manipulation techniques
between the pain response and the degree of com pression required to provoke this response. •
The response to treatment was very good. After 2� weeks he could stub his toe firmly with only the slightest discomfort.
Noel et al (2000) have presented a preliminary clinical observational paper based on adding compression to mobilization in rehabilitation after knee surgery. First of all they review an existing protocol for the clinical application of compression proposed by Van Wingerden (1995). This protocol suggests that: •
•
•
compression should be carried outfrom end-of range motion into the range of motion 3-5 series of 15-25 compressions should be carried out daily dynamic movements such as walking or cycling should be carried out as home exercises.
Noel et al then took 30 patients following anterior cru ciate ligament (ACL) reconstruction and looked at how quickly they reached a target of 130° of knee flex ion (normally 4 weeks). One group of 15 was assigned to an active rehabilitation programme and one group of 15 was assigned to an active rehabilitation pro gramme and mobilization under compression at the start of each rehabilitation session. The protocol for the mobilization with compression was as follows: • •
•
•
•
•
•
•
The patient was positioned in supine lying. A sand bag was placed under the knee proximal to the pa tella. The knee was flexed to full available range of movement into flexion. Progressive compression was applied to the knee through the tibia via the calcaneus. The amount of compression was adapted to the patient's response to avoid pain. The knee was moved, under compression, through a range of 10-15° from full available flexion towards extension. At the end of each movement the compression was released as the knee was returned to full available flexion and the process repeated. Four series of 20 mobilizations with compression were performed. Each series was followed by four to five full range passive mobilizations.
The results of the paper by Noel et al show that only one patient dropped out of the control group and three out of the experimental group and that the experimen tal group reached the target of 130° of flexion in half the number of sessions compared to the control group,
with the largest gains coming in the first two sessions. The authors then go on to discuss the potential impli cations of adding compression to joints in terms of its potential effects on synovial fluid function and the car tilage matrix. Evans (1998) has succinctly reviewed the changes that occur in synovial joints with ageing, Le.: •
•
• • •
articular cartilage becomes thinner, yellow and less elastic ligaments are less elastic and rupture at lower stress levels the whole joint is stiffer and weaker proprioceptive afferents are fewer and less competent the blood supply to the joint becomes less competent and, consequently, so does the healing process.
Evans goes on to explain that articular cartilage nutri tion occurs by rebound suction. The spongy joint sur faces are squeezed together and synovial fluid is swept across aLL the joint surfaces. He proposes that 'sweep and squeeze is the name of the game'. He then goes on to rec ommend what should be encouraged and what should be avoided to lessen the consequences of ageing. •
To be encouraged are: any movement; exercise or movement which achieves compression of all artic ular cartilage (full range, close packed, combined movements); regular cyclical load-bearing exercise or movement.
•
To be avoided are: long term immobilization, espe cially if this is non-weight-bearing; excessive impact loading (on hard surfaces, with weight and at speed); excessive shearing type stresses across the joint.
Selection and progression of treatmen t for intra-articular disorders including severe restrictive intra-articular pain and minor symptoms with compressive loading The clinical profile for intra-articular disorders is detailed in Chapter 10 along with the pattern recogni tion and expectations for recovery of the all the cat egories of osteoarthritis. Severe restrictive intra-articular pain Patients who have marked restriction of movement due solely to pain felt within the joint.
•
•
The greater the severity of pain, the greater will be the restriction of joint movement inhibited by pain. The disorder also has a high degree of irritability, i.e. it takes very little to provoke severe pain, and
21 7
218
M A ITLA N D'S P E R I P H E R A L M A N I P U LAT I O N
this increased pain takes considerable time to sub side to its usual level. •
Examination and treatment need to be kept to a minimum.
•
The aim of the treatment technique is to perform the largest possible amplitude of movement which the joint can accept without exacerbation, be it an acces sory movement or a physiological movement. The larger the amplitude of the treatment movement possible, the better is the effect.
•
When a movement is markedly restricted by pain alone, the first choice of treatment technique is to use an accessory joint movement while the joint is positioned in its most comfortable position.
•
Figure 8.66 shows a posteroanterior gliding move ment of the head of the humerus in relation to the glenoid cavity while the arm is supported with pil lows in its most comfortable position. This position is usually a mid-range position of all the joint's accessory and physiological movements.
•
At the first and second treatment sessions when pain is severe and irritable the posteroanterior accessory movement must not: - produce any feeling of discomfort or awareness of uncomfortable joint movement during the performing of the technique - cause any aching in the joint.
•
Posteroanterior movement is not the only accessory movement that can be used; lateral movements of the head of the humerus, longitudinal movement caudally or anteroposterior movements may also be effective in reducing the severe restrictive intra articular pain.
•
To these movements can be added a shaft rotation movement of the humerus in a mid-range 20° arc, even though this is not an accessory movement.
•
During the performing of the passive movement technique the physiotherapist must: - be totally aware of what the patient feels within the joint from the moment the technique is commenced - be totally aware of any changes in what the patient feels as the technique is continued.
•
Four elements are used in making these assessments: 1. the verbal communication between physiothera pist and patient, achieved by continually asking questions regarding the effects on the joint symp toms while the technique is being performed 2. sufficient awareness to notice any nuances in the non-verbal communication (e.g. frowning, squeez ing the eyes tightly shut, flinching, clenching the fists) 3. while performing the technique the physiothera pist must be aware of even the most minimal muscular protective response, brought into play as an automatic subconscious means of protect ing the joint from discomfort 4. the therapist must also be aware of any changes in the feel of friction-free movement while per forming the technique.
The effectiveness of the technique can be measured by determining: subjective changes 'in' the shoulder during the performing of the treatment technique 2. subjective symptomatic changes 'in' the shoulder following treatment 3. objective changes in range and quality of active movement as a result of treatment 4. the time taken for any increased symptoms from testing (3) to subside, compared with the pretreatment measurement. 1.
Such approaches to treating severe restrictive intra articular disorders can reduce pain and improve move ment rapidly if selection of the patient is correct. If the disorder is an active disease in the acute inflammatory stage, however, this will not be the case. Such techniques may be considered to be 'surface stirring' without load, to which Lowther (unpublished observation 1983) refers.
Fig u re 8.66 Posteroanterior movement of the hu meral head while the a rm is placed i n its most comfortable position.
M inor symptoms with compressive loads Such patients present with minor symptoms of intermittent aching in a joint, felt only when the joint has to cope with
Principles of selection and progression of mobil ization / manipulation techniques
heavy work or when it has been subjected to passive sustained compressive forces, such as lying on the shoulder or hip at night. Patients with minor symptoms on compression fit into the severe restrictive intra-articular group but at a different or less intense stage. The continuous passive motion described by Salter et al (1980) would not improve the patient's symptoms or the physical cap acity of these troublesome joints. However, if those same movements are performed with the joint sur faces firmly compressed together, as described earlier, then the technique can be effective. Maitland (1985a) gives examples of the clinical importance of adding compression when examining and treating synovial joints (by kind permission of the publishers): 1. Clinical experience related to pain response is demonstrated by the following example. A painful metatarsophalangeal joint of the big toe is paSSively rotated in a small amplitude (say 10°) oscillatory manner in mid-range. As the oscillatory movement is performed in mid-range, no ligaments or any part of the capsule should be stretched or put under ten sion. Then if the same oscillatory movements are performed with the opposing joint surfaces com pressed together, exquisite pain is provoked; yet when the same movements are performed without compression, no pain occurs. The examiner is there fore drawn to the conclusion that there must be some mechanism whereby pain is evoked from the joint surfaces or the subchondral tissues.
compressed is readily appreciated by the examiner and by the patient (Fig. 8.67). These examples, along with the presented pathobiolog ical and clinical evidence, adds strength to the proposal that passive movement of a joint should sometimes be performed with the adjacent surfaces compressed.
Periarticular joint structures and function •
Flint (1976) and Gillard et al (1977) have demon strated the importance of intermittent tensional forces on the maintenance of the structure of the Achilles tendon in rabbits.
•
Lowther (1979) reports that 'it seems likely that . . . tensional forces are important for the maintenance of ligaments and tendons in the joint and perhaps in the joint capsule itself, since Akeson et al (1973) demon strated increased stiffness and matrix changes in the joint capsule from immobilized rabbit joints'.
•
Frank et al (1984) acknowledges that motion and stress appear to help in the quality of healing of ligaments after injury.
2. Clinical experience related to smoothness of move
ment is based on the premise that if a normal synovial joint is moved passively back and forth through an arc, irrespective of whether joint surfaces are com pressed together or only lightly opposed, the move ments will have an identical feel of being smooth and friction-free. When patients have joint surface disorders, however, a resistance to tlle movement through range can be felt when the surfaces are moved while being compressed together. For exam ple, ask any yOWlg person with a normal ankle to lie prone Witll one knee flexed to a right angle while you face the leg and hold the bare foot firmly in both hands. Stabilize the grip against your chest and chin. In this position rock your trunk from side to side so that the person's ankle is oscillated in a 30° mid-range arc of dorSi/plantar flexion. The ankle movement should be felt to be just as smooth whether minimal or maximal body weight is trans mitted through the foot. If this same test movement is carried out on an osteoarthritic joint, the loss of friction-free feel when the joint surfaces are
Figure 8.67 Ankle dorsi- and plantar flexion with compression.
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M AITLA N D ' S P E R I P H ERAL M A N I P U LATI O N
•
Hunter (1994) states that research has shown that calculated and controlled motion of healing soft tissue influences the healing process, giving an improved functional outcome.
•
Van Wingerden (1995) details the effects of mobil ization on injured ligaments, i.e. increased synthe sis, proliferation of fibre orientation maturation, increased tensile strength, return to normal proper ties and characteristics.
Again there is a clinical application to parallel this evi dence which can be related to the two extremes of pain and functional loss from ligamentous or capsular injury, damage or change. Treatment by passive move ment, therefore, can be applied to patients whose dam age is recent and quite painful when stretched and patients whose disorder is of a longer standing and more chronic nature (Maitland 1985b). On the one hand mobilization techniques can be used to comple ment and maximize the healing potential; on the other hand techniques can be used to remobilize capsular and ligamentous tissue or reintroduce such tissue to movement it has lost.
Recent periarticular damage •
Use techniques consisting of small amplitude pas sive movements performed slowly, with full aware ness of the pain response, and repeated in groups of approximately five movements.
•
These movements aim to apply gentle intermittent stretch provoking only minimal discomfort.
•
The groups of intermittent stretching can be per formed many times, provided there is no increase in the pain response with the movement.
•
Assessment of the effects of the passive movement treatment is made over the 24-hour period follow ing treatment and the information gained guides how the intermittent stretching should be modified at subsequent treatment sessions.
•
An increase in pain indicates that the stretches should be even more gentle. An increase in range and a reduction in pain indicate that the movement can be performed deeper in the range producing the same pain response as the previous treatment.
•
Special techniques to influence the pain after injury (Chapter 2) and movement to help to create an ideal environment for healing of the ligament or capsule (desired effects) can be applied as soon after the injury as is practical. Hunter (1994), however, sug gests that the gentle stretching techniques to help in
the recovery of the tensile strength of the soft tissue can be started from the fifth or sixth day after injury as this is when collagen begins to be laid down. The stretches should be progressed gradually until healing is complete.
Chronic periarticular stiffness with minor pain The treatment principles of stretching techniques are almost identical to those described above in these patients. The exception is that the stretching needs to be much firmer. Many physiotherapists are unaware of how strong some passive movement techniques
Intermittent tensional forces may be required to be stronger in order to be more effective than if such forces were not applied. The guideline to how strong the technique needs to be is primarily based on the necessity to produce a sharp 'bite' of pain, given that the kind of periarticular disorder being considered here is not one where the structures are disadvantaged by disease, recent surgery or disruption. The stretch should be gradually and progressively increased until the 'bite' of pain is achieved for the technique to be effective. The number of stretches into the 'bite' should be few in number (4-6), not sustained once the 'bite' has been achieved and slowly built up in tension. The patient must do stretching at home to retain the increased range of movement gained from treat ment. Such home stretches should be performed in the same manner as treatment, allowing sufficient time between stretches into 'bite' for the discomfort to totally subside. Damage does not occur, despite the 'bite' of pain, provided that the passive movement is momentary and intermittent. Figure 8.68 shows an example of stretching ankle dorsiflexion where the movement is gradually taken near to the limit of the range, then taken into a momen tary 'bite' of pain and immediately released. Figure 8.69a shows the position the patient should adopt in stretching into dorsiflexion as a home exercise. While keeping the heel on the floor the knee should gradually be pushed further forwards until pain is reproduced. This position should then be sustained until the pain subsides. The knee is then moved further forwards, again pausing for the pain to subside, until the limit of range is reached. Having performed this routine of pro ducing 'bite' two or three times, the patient should then, before releasing dorsiflexion, attempt to lift the ball of the foot off the floor without uplifting the heel (Fig. 8.69b). The patient should continue trying to lift the ball of the foot until eventually the whole foot is lifted need to be.
Principles of selection and progression of mobilization / manipulation tech n iques
221
] off the floor at the maximum dorsiflexion active range (Fig. 8.69c). After completing the routine, when releas ing the dorsiflexion the patient is likely to experience quite severe sharp pain, but it quickly disappears with repeated active, loosely performed, dorsi/plantarflexion movements. The desired effects of treatment will have been achieved if the chronic stiffness and pain diminish.
SELECTION AND PROGRESSION OF TECH NIQUES BASED ON THE ONSET, INJURING MOVEMENT, AND T HE STAGE AND STABILITY (LABILITY) IN THE NATURAL HISTORY OF THE DISORDER ------
Figure 8.68
(a) Figure 8.69
Selection and progression of treatment based on the aspects of the history of the disorder may be influ enced more in relation to the vigour and the duration of the treatment rather than the technique itself. Knowledge of such factors as the onset of the symp toms (traumatic, spontaneous, episodic, gradual), the extent of damage and the mechanisms involved with any injuring movement, the stage in the natural history of the disorder (pathological development) and the degree of current activity or stability lIability of the dis order, may guide thinking related to the changes and rate of change in symptoms that can be expected to take
Passive dorsiflexion stretch into 'bite'.
(b)
(c)
(a) Passive ankle dorsiflexion ; (b) active ankle dorsiflexion for the position of maximum passive dorsiflexio n ; (c) active ankle dorsiflexion.
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M A ITLA N D'S P E R I P H E R A L M A N I PU LAT I O N
place with treatment. This understanding will influ ence the way treatment techniques may be changed and progressed. Selection of techniques based on the history of the disorder may relate more to the desired effects which need to be achieved with treatment such as: •
•
•
•
creating an ideal environment for healing and to complement the healing process after a severe ankle sprain kick-starting the recovery after a long period of immobilization following a wrist fracture restoring full range of movement in the stiff painless stage of adhesive capsulitis maintaining function in a patient's elbow after an active episode due to rheumatoid arthritis.
Knowledge of the injuring activity, injuring movement and the extent of the damage so caused will influence both the selection of the treatment direction, the expected rate of progression and even the eventual outcome. A patient who has a minor strain of the medial ligament of the knee after a twisting injury will recover much quicker with gradual stretching into the rotation-injuring direction than a patient who has rup tured an anterior cruciate ligament and undergone reconstructive surgery and who will require mobiliza tion over several months related both to the injury and to the effects of surgery. Many neuromusculoskeletal disorders have a nat ural history and go through predictable stages of recov ery, flare-up episodes or lability. The key in selection of techniques is to establish which stage in the natural history the disorder is in at present and select the tech nique, vigour and duration that are appropriate to the current stage or pathological activity of the disorder. For example: 1.
An osteoarthritic hip of longstanding duration with episodes of inhibiting pain, and currently being within a painful episode, would require techniques aimed at pain relief. The degree of activity of the inflammation would influence the technique used (painless accessory movements if very active; pain less physiological movements if not very active) and its rhythm (slowly and smoothly if very active; quicker if not very active).
2. An inactive capsular disorder that is stable and late in its stage of progression would require stretching techniques, both physiological and accessory end of-range movements. 3. A recent sprain (a day or two ago) that has occurred for the first time and that is stable in terms of reaction to the sprain, will require very slowly performed
movements in the clirection of the sprain and into a very small degree of 'hurt'. At a late stable stage of the reaction to the sprain other physiological move ment techniques can be added; later still, more local ized techniques and moderately firm accessory movements are added.
SELECTION AND PROGRESSION OF TECHNIQUES BASED ON PATHOBIOLOGICAL MECHAN ISMS (DIAGNOSIS, PATHOLOGY, MECHAN ISMS OF SYMPTOM PRODUCTION , RECOGNIZABLE SYN DROMES) Where a definitive diagnosis of a patient's disorder is possible, the choice of passive movement techniques will be influenced. Take for example a patient with a locked knee due to a torn medial meniscus. The desired effect of any technique in such a case would be to restore the joint to its pain-free full range status. To achieve this desired effect, the therapist must choose a movement or combination of movements that gap the medial joint space, followed by repeated physiological movements of rotation, flexion, and extension. How the technique is performed (grade and rhythm) will still depend on the information gained about the behaviour of the symptoms. Similarly, the specific movements used to 'unlock' the knee will depend on the history of how the knee locked and any previous episodes and the presenting signs. Another example of diagnosis affecting the choice and progression of treatment is 'frozen shoulder' which has three distinct stages of severe pain, stiffness with less pain and stiffness without pain. Each stage requires quite different treatment techniques based on the history, and signs and symptoms. Diagnosis influences the choice of technique in another way. If a patient has rheumatoid arthritis with obvious changes to the joint and its supporting struc tures, yet has a strained wrist and is, as a result, unable to lift objects that could be lifted easily prior to the injury, any passive movement treatment (any treatment at all really) must take into account the underlying tissue weaknesses caused by the rheumatoid arthritis. Thus certain pathologies and diagnoses will place restraints on treatment. A reverse situation occurs with the diagnosis of 'frozen shoulder' i.n its third stage (Corrigan & Maitland 1983). This stage calls for posi tive firm treatment techniques whose desired effect should be to markedly increase the range of movement. During the cycle of any pathological process whether it be a 1-week-old fractured neck of humerus (group 1) or a stiff osteoarthritic hip (group 2 or 3b) the joint signs which present will correspond to one of
Pri nciples of selection and progression of mobilization/manipu lation tech n iques
the clinical groupings described earlier i n this chapter. Also during this cycle the joint signs will change with time as will the clinical group to which the joint signs correspond. In such cases selection and progression of the techniques can be changed accordingly. For example, a patient may present with a severely painful 'tennis elbow' (groups 1, 3a) which requires pain-free small oscillatory movement (posteroanterior movement of the head of radius) to influence the severity of the pain with elbow extension. After a few weeks this severe pain may have subsided and the patient is left with discomfort and stiffness when straightening the elbow (groups 2, 3b), in which case these signs and symptoms are more likely to resolve if the elbow is gradually (respecting pain - group 3b) stretched into elbow extension and extension/adduction, extension/ abduction. Once again it should be emphasized that scrupulous assessment of symptoms and signs through out treatment is essential if techniques are to be adapted effectively. The importance of an understanding of the mech anisms involved in the prod uction of the patient's symp toms and the influence this will have on the selection and progression of passive movement treatment tech niques has come to light due to the work, for physio therapists, by Gifford (1997) and Butler (2000). These mechanism categories (nociception, peripheral neuro genic, central pain, sympathetically maintained pain and affective/cognitive dimensions) are reviewed in Chapter 10. The manipulative physiotherapist must be aware of the way that passive movement techniques can also influence and perpetuate tl1ese mechanisms and therefore affect the way and the rate that the patient recovers from a disorder and any future disorders or episodes, i.e. the way the therapist deals with the cur rent episode can influence the way a patient will sample and deal with any fuhue episodes or disorders (Gifford 1998). Techniques therefore should be selected which take into account not only the restoration of the dis ordered neuromusculoskeletal tissue to as normal a state and function as possible, but also how the patient will remember the experience of having the acromio clavicular joint oscillated in order to relieve the pain of an acute injury or the hip stretched into flexion/ adduction to the 'bite' of pain in order to improve the aching and restricted movement being experienced. Likewise, the therapist must be able to deal with the allodynia (hypersensitivity) around an injured lateral ligament of tl1e ankle in conjunction with mobilizing the ligament itself, i.e. involvement of the peroneal nerve should be suspected, investigated and dealt with (Butler 2000). Sensitivity and sympathetic maintained pain around the elbow should be considered in patients
with lateral epicondylalgia who have not responded to locally directed treatment. In such cases movement impairments in the thoracic spine or peripheral neuro genic tissues may be contributing to this mechanism and need to be addressed and dealt with before the local tissue can fully recover. A patient who is suffering with anterior knee pain may have lost trust in the knee because it is constantly giving way due to pain. The patient may be fearful of certain activities and has developed maladaptive avoid ance strategies such as going down stairs one at a time. Of course, this will perpetuate the symptoms and be a barrier to recovery. It is the job, therefore, of the manipu lative physiotherapist on the one hand to identify the local impairment, which may be a patellofemoral intra articular disorder, and deal with it and on the other hand gradually help the patient to regain trust in move ment by explanation, rehabilitation and reassurance that once the pain has settled the giving way will grad ually diminish and then normal functional movement will keep the knee healthy and less likely to be a prob lem again in the future. Each peripheral region (Chapters 11-17) contains a review of common and recognizable syndromes par ticular to that region which have recognizable histories and often respond in predictable ways to mobilization techniques. Other categories of disorder which are worthy of note in terms of selection and progression of techniques are: •
•
• •
arthritides (Chapter 10): - osteoarthritis - subclinical arthritis - rheumatoid arthritis - post-traumatic arthritis fractures - impacted fractures - non-uniting fractures - fracture sites hypermobility locked joint loose bodies.
Osteoarthritis The physiotherapist most certainly has a role to play in the treatment of the osteoarthritic joint (Fig. 8.70). This is so even when the joint (e.g. hip) may in future require surgical replacement. •
When a patient has pain within the hip and has marked radiological cl1anges in the hip (loss of joint space and flattening of the head of the femur) it is still possible to both reduce the pain and improve the quality of its movements and its ranges.
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Phase 3
90° hip / knee flexion position. The result was good and she could walk long distances without discomfort and could use stairs quite well. She was pleased and treat ment was discontinued except for her own exercising and a single 6-weekly 'maintenance treatment' session. One year later she had a fall, landing on her hip. This triggered off an exacerbation of her osteoarthritic
Figure 8.70
Arthritides: treatment.
symptoms. This time she gained nothing from the same physiotherapist and hip replacement surgery was per formed. The surgeon's postoperative comment was particularly poignant: 'I have never seen the structures
•
In the initial stages while pain is the primary factor,
surrounding the hip in such a healthy state, it was quite
accessory movements produced by pressures applied
remarkable.'
to the greater trochanter are the first choice. •
The patient is positioned to lie on the sound side with both hips and knees flexed comfortably and the upper foot and leg fully supported with pillows between the legs.
•
Care needs to be taken to support the foot and ankle
than usual. This example reveals a second and significantly important aspect to manipulative physiotherapy for the painful osteoarthritic hip. The same applies to other similar disordered synovial joints.
so that the femur 's shaft rotation is in a neutral
Another point is raised by this experience. When
pain-free position - frequently this is not cared for
treating any synovial j oint that has radiolOgical evi
adequately. The same treatment care is taken as for group •
She had a good result from the surgery, responding to treatment and recovering at a decidedly quicker rate
1 or 3a patients.
Assessment is carried out impeccably and a written (even graphed) record is kept b y the patient as it is an essential component of the analysis of the state
dence of osteoarthritic change, even if a periarticular structure is the part being treated, the intra-articular changes should also be given the advantage of grades II or ill- treatment which may stimulate nutrition and better function.
of the disorder and its likely prognosis with manipu lative physiotherapy. •
The ultimate aim with such a disorder is to be able to perform large amplitude, brisk, shaft rotations in the side lying position described above, or to be able to reach a stage of large amplitude hip flexion adduction movements (from an extension adduc tion or even just an adduction position in the same flexion position).
•
Subclinical arthritis Subclinical arthritis is discussed at length in Chapter 10. Its management - particularly in relation to what the physiotherapist has to offer both in terms of treatment and in suggestions for other treatments that can be undertaken - is properly and valuably the therapist's role. Its mobilizing treatment would be in the group
1
category as is that for 'jointy people', where the tech
The patient should be taught loose pendular exer
niques would be directed at the pain. Such joint disorder
cises to be carried out three or four times a day, and
is slower in its response than is the mechanical variety of
even at night if wakened by pain.
arthritis; in fact it is its slower response that is one of the
There is another reason for saying that the physiother apist has a role in treating these patients, as shown by the following example. A woman has a radiologically bad osteoarthritic hip and was having a degree of pain that led the surgeon to say that a hip replacement operation was necessary. The patient did not want this and was referred to a physiotherapist for treatment. Because the degree of
leading factors in its differentiation. If it responds only slightly in the first four sessions, the improvement may well be enhanced by anti-inflammatory medication. (Mechanical inflammation is often helped less by anti inflammatory medication.) If the result of combining medication with mobilization is still incomplete, an intra-articular injection of hydrocortisone could be expected to be very successful.
attainability was sufficiently low to allow flexion adduction movements to be used for treatment, these were performed and progressed as for group 3b patients
Rheumatoid arthritis
as described earlier. Shaft rotation as grade ill was
Passive movement techniques are never successful in
added in both the flexion-adduction position and the
relieving pain caused by an active rheumatoid arthritis.
Pri nciples of selection and progression of mobil ization / manipu lation techniques
However, i f the rheumatoid arthritis i s not active and the patient complains of pain or aching of more recent origin, there may be a mechanical reason or minor recent trauma which is responsible for the pain. Under these circumstances gentle grade IV- techniques should relieve this pain. Firm techniques should never be used on joints exhibiting rheumatoid arthritic changes because the ligaments and tendons around the joint are structurally weakened by the rheumatoid disorder.
Figure 8.71
Osteoarthrotic and post-traumatic arthritis
Non-uniting fractures
Pain resulting from osteoarthrotic joints or from long standing traumatic arthritis can be very readily improved by large amplitude movements within range.
(Reproduced from McNair, J. and Maitland, G. D. (1983) The role of passive mobilization in the treatment of a non-uniting fracture site - a case study. Presented at the International Conference on Manipulative Therapy, and reproduced by kind permission of the Manipulative Therapists Association of Australia.)
•
•
•
When pain is severe, movements of large amplitude should be used but they should be performed painlessly as accessory or rotary movements in a neutral position. As pain recedes, large amplitude physiological movements should be used, initially without provoking pain. As the condition continues to improve the large amplitude movements can be taken into pain and probably to the end of the available range of movement.
Fractures Impacted fractures •
Injuries that result in fractures (Fig. 8.71), for exam ple of the surgical neck of the humerus, are usually severe enough to cause damage to ligaments and capsule, thus laying the basis for a stiff gleno humeral joint.
•
Passive accessory movements of the glenohumeral joint in its neutral and supported position (see Fig. 11.44) can play an extremely vital part in retaining maximum movement without any stress on the frac ture. The significance of this early treatment cannot be overemphasized: it is extremely important to real ize that a good functional range can be retained with out the fracture being subjected to stress (see p. 230).
•
Abduction is a very important glenohumeral move ment. The movement can be performed as part of treatment in all fractures of the humerus if the full length of the humerus is supported throughout the movement with one arm, while one or more fingers of the other hand assess movement between the head of the humerus and the acromion process.
Phase 4
Fractures: treatment.
To date, passive mobilization has always been directed towards creating movement at a joint, by applying mechanical pressures to the adjacent bones, the aim being to relieve pain and increase range of movement. However, since 1982 we have had the opportunity to apply certain passive mobilization techniques to the adjacent bone at a fracture site. Here the aim was to stimulate union at a particular fracture site which was already showing signs of non-union on X-ray and the medical specialist was considering surgical intervention. This presents a challenge in two areas:
1 . That of fracture management which has historically and classically disallowed movement of fractures. 2. That of 'end-feel', where originally there was no predictable concept of 'end-feel' to the movement since we, as physiotherapists, have not as yet developed a bank of knowledge or skill of 'feel' in this area. Thus the choice of technique in this case did not purely follow our usual principles of applying techniques in that it was not based upon the behaviour of symptoms through range of movement or at rest. Instead it was based upon the following: 1.
The recognition of the patient's ability to appreciate 'fracture site pain', as distinct from all other types of pain, during movement of the fracture. 2. An academic extension of the concept of accessory movement and 'end-feel', with a knowledge of the orientation of the fracture lines and its internal fixation.
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[ CAS E STU DY A 40-year-old m a n, who had been shot, was adm itted to the Royal Adelaide Hospital on 1 7 September 1 98 1 . H e h a d a n entry w o u n d just u nder h i s xi phisternum and had some bleeding from his left el bow, which was unstable. The bullet had passed through his left elbow joint and entered his chest. H e was resuscitated and underwent a laparotomy on the day of admission. The X-rays taken on the day of admission are shown in Figu res 8.72 and 8.73. On the fol lowing day ( 1 8 September 1 98 1 ) his elbow was explored i n theatre. The fi ndings were a fractu red latera l epicondyle and a fractured olecranon with the articular su rfaces of the el bow joint slightly scoured. Fou r pieces of lead a n d frag ments of loose bone a n d carti lage were found in the a rea. The lateral epicondylar fracture was red u ced 'with a good match of a rticu lar su rface' and held with K-wi re fixation. The fractured olecranon was reduced with 'anatomical a pposition of the fragments' and held with tension wire fixation. Fig u res 8.74 and 8.75 show the X-ray views take after surgery. His elbow was then encased i n a plaster-of-Paris cast which mainta ined satisfactory reduction as shown i n Figures 8.76 a n d 8.77. H e made a good recovery and was discharged 1 0 days later (29 September 1 98 1 ) . An orthopaedic fol low-u p of his el bow was a rra nged on 5 November 1 98 1 . After removal of the plaster-of-Paris cast, at this fol low-up,
Figure 8.72 X-ray: lateral view taken o n date of admission (17 September 1 981 J.
Figure 8.74 X-ray: lateral view taken after surgery on 1 8 September 1 981 .
Pri nciples of selection and prog ression of mobil izatio n / m a n i p u lation techniques
t h e patient received treatment for his elbow t o i m prove h i s range of movement. At a subsequent orthopaedic fol low-up on 1 0 December 1981, about 4 months after i njury, his ra nge of movement was considered to be 'functional' with a fixed flexion deformity of 65' and his active flexion l imit was a l most fu l l range, at 1 35'. His ra nge was reported to be i mproving with physiothera py. The fol low-up X-ray report (radiogra phs taken on 1 0 December 1 98 1 ) noted that the olecranon fracture showed signs of u nion, while there was som e 'rounding off of the lateral epicondyle fragment, with associated widening of this fracture site. Figures 8.78 and 8.79 show the X-ray views taken at this orthopaedic fol l ow-up. The senior orthopaedic registrar reported that the epicondylar fracture was progressing to non-union and, upon further d iscussion with the orthopaedic surgeon i n charge o f t h e patient it w a s decided t h a t i n 1 month's time (on 1 5 January 1 982) the K-wires woul d be removed and replaced with a compression screw. The surgeons were particu la rly concerned because the fracture was caused by a bul let, which causes heat damage to the
Figure 8.76 1 98 1 .
X-ray: lateral view taken o n 25th September
Figure 8.77 1 98 1 .
X-ray: anterior view taken on 25th September
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M A I T LA N D'S P E R I P H E RA L M A N I P U LAT I O N
L
Figure 8.78 1 98 1 .
X-ray: lateral view taken on 1 0th December
bone cel ls and ca pillaries within t h e Haversian system, d i m inish ing the usual fractu re haematoma and thus the chance of u n ion. Avascu l a r necrosis of the lateral epicondyla r fragment was therefore a l i kely com plication. Meanwhile, the orthopaedic su rgeon gave his consent to a trial of passive mobilization of the latera l epicondyle w h i le the K-wires were in situ, with a view to sti m u lating union. Passive mobil i zation commenced on the 1 6 December 1 981 . This was 3 months after the incident, when the signs of non-union were present on X-ray. The patient was treated daily for a pproximately 1 month. Treatment consisted of su pporting his arm in a comfortable degree of flexion (about 65') with the patient supine; g ripping his lateral epicondyle between the thumb and index finger; then mobilizing the epicondyle. The techn ique used ca n be described as a combined anteropostero-a nterior movement (Fig. 8.80), accompa nied by com pression of the lateral epicondyle i nto the h u merus (Fig. 8.81). The compression was a medially d i rected grade IV+ + + sustained pressure, w h i l e t h e a nteroposterior-anterior pressure was a grade IV g l ide. This very sma l l ampl itude g l iding was obviously modified by the presence of the three K-wires, wh ich probably caused the g l iding pressure to i nclude a tipping action. The compression component,
Figure 8.79 1 981 .
-
X-ray: anterior view taken on 10th December
Antero posterior pressure
,
t
Postero-anterior pressure Figure 8.80
Lateral view: lower humerus with K-wires
in situ.
which was the main component of pressure, was not affected by the presence of the K-wires since it was directed al most para l lel to their orientation. There was not a lot of movement present and the 'end-feel ' could only be described as tight and sl ightly 'gritty'. The degree
Principles of selection a nd progression of mobil ization / manipu l ation techn iques
o f treatment was infl uenced b y the intention t o provoke a sma l l degree of 'fracture site pain' intermittently. This was deemed essential since it confirmed that the tech nique chosen was effectively creating movement at the fractu re site. On 1 4 January 1 982, about 1 month after passive mobil ization was i nstituted, the patient was readmitted to the Royal Adelaide Hospita l and X-rays were ta ken. These showed signs of union over a sma l l a rea of the fracture site ( Fig. 8.82).
The surgeons felt that removal of the K-wires and screw fixation was sti l l indicated, but that treatment might be modified dependent u pon fi ndings at surgery the next day. His ra nge of elbow movement was assessed, i n theatre, as 1 0- 1 40· flexion, showing i ncreased ra nge, and u po n removal o f the K-wi res the surgeon was unable to manually move the lateral epicondyle. The su mmary of the surgery states that there was u n io n t h roughout and therefore a l l i nternal fixation was removed.
Discussion
Figure 8.81 Anterior view: lower h umerus with K-wire fixation of lateral epicondyle.
As mentioned previously, this application of passive mobilization in a controlled way to a fracture site, instead of a joint, challenges the historical and classical management of fractures as advocated by Hugh Owen Thomas (1834-1891). He along with his pupil, Robert Jones, laid down the ideals of orthopaedic fracture management as rest, support and immobilization. These ideals influenced orthopaedic practice for the first half of this [20th] century. The concept of compressing fractures by early weight bearing, for internally fixed lower limb frac tures, was first advocated by Delbet in 1906 but was not universally accepted until 1929 when Bohler in Vienna adopted this practice. However in recent years, particularly in the last decade, many authors have researched the healing of bone in the presence of compression and electrical currents. Interestingly, authors such as Peacock and Van Winkle (1976) ascribe a possible piezoelectric property Figure 8.82 X-ray: lateral and anterior views taken on 1 4th January 1 982. This was 1 month after passive mobilization and the anterior view appea rs to show union at the epicondylar fracture site.
229
230
M A ITLA N D 'S P E R I P H E RA L M A N I PU LATI O N
L
(1979) has
to the crystalline nature of bone, enabling i t to act
relation to the 'Resters' and 'Movers'. Jull
as a stress transducer. Bone healing is thought to be
very clearly described the application of mobilization of
enhanced in the presence of small electrical currents
joints following fractures.
which are produced when the crystalline components of
Treatment of ununited fractures since the example
bone are distorted by mechanical compression. Many
described above has been equally successful and the
authors have subsequently also studied the effect of electrical currents on bone union (Hassler et al
1977,
majority had been unsuccessfully treated by electrical stimulation beforehand.
Panjabi et al
1977). Of particular interest, an article by (1979) outlined a biomechanical study
surgeons that the use of passive movement techniques,
of the effects of constant and cyclic compression on frac
such as those described above (McNair & Maitland
Yasuda
It is considered in Adelaide by some orthopaedic
ture healing in rabbit long bones. Their findings showed
1983), would hasten the union of intervertebral fusions,
that constant compression, as in internal fixation, pro
if applied immediately after the surgical procedure.
duced a stronger bone during the early phase of healing. They also found that there was a
27% reduction in the
healing time of bone stimulated by cyclic compression.
Hypermobility Hypermobility is very helpfully discussed by Beighton
Conclusion
(1983). Hypermobility (general and local), instabi 1976)1 are explained in Chapter 10, as are pain inhibition and
et al
While the result of union in this case study indicates that passive mobilization of the fracture site, at best, either stimulated or aided union, and at worst, did not prevent spontaneous union, it is important to empha size that care was taken to make compression the major component of pressure and that the amplitude of anteroposterior-anterior gliding was minimal. It is
lity, and stable-instability (Williams et al
apprehension. 'Sprains', including ligamentous tear ing and rupture can also be considered under this heading of hypermobility. In terms of treatment, the following should be considered: 1.
When a patient who is generally hypermobile has
also worth emphasizing that passive mobilization was
symptoms arising from one of the hypermobile
3 months after fracture when signs
joints, it is treated in exactly the same manner as that
not instituted until
of non-union were present on X-ray. Thus the type of technique and the timing of treat ment must be considered in any future study of the role of passive mobilization in the management of fractures.
described for a hypomobile joint.
2. A joint that becomes hypermobile through training, as for a ballet-dancer, may not reach a stage with the training to be sufficiently hypermobile for the expertise required. If the person has great potential
Fracture sites
in the chosen field, the physiotherapist can help gain
The above leads one to treating fracture sites from the beginning . It is the practice in China for fractures to be supported in bucket splints which are removed by the patient on a daily basis when he moves his limb a small number of times. The splint is then replaced for the remainder of the day. With multiple unstable fractures in one limb, such a procedure may not be contemplated. However, it is common practice to have a patient with a fractured femur walking in a plaster or Thomas splint.
the extra range required by techniques described for group
2 patients. The techniques would be sup
plemented by training sessions, but a longer period of warm-up is required and also a longer period of time on the one functional movement being treated. Obviously, active control of this increased hyper mobility is essential and incorporated into the patient's treatment and training sessions.
3. Stable-instability and pain inhibition usually occur
Therefore, to have the patient in a non-weight bearing
together and is common in the knee. When present
(or partial weight bearing) calliper or a bivalve plaster
in the knee, there is an extension-lag, and over
should be acceptable. If then a skilled physiotherapist
pressure of extension combined with tibial antero
removes or partially removes the splint and uses pas
posterior
sive movement in the manner described above, which is
consists of:
successful with non-uniting fractures, it should shorten
(a) Knee extension with anteroposterior movement
the time needed for splinting. Equally important,
into a tolerable degree of hurt as a grade
pressure
is
painful.
The
treatment
a better range of movement . and function of the joints affected by the fracturing incident is achieved if the joints encased in the support would also be moved. Professor Salter's articles
(1982, 1985) are a 'must' in
J.G.P and Sperryn, P.M. (eds.) Sports Medicine, London, Edward Arnold, pp. 441 and 586 ( 1 976)
1 Williams,
Principles of selection and progression of mobil ization/ manipu lation techniques
IV- progressing to grade I V + (and later IV + + )
range and totally painless. (Other directions of
interspersed with grade III- movements.
movement would also form part of the treat
(b) Accessory movements, and especially tibial
ment.) Once the unstable direction of the knee
shaft rotation, are used at the comfortable limit
is painless (and all other movements are pain
of knee extension, as grade III- movements.
less) re-education can be promoted as rapidly
4. Apprehension movement is treated by performing
as possible.
that movement slowly, nudging at the point of the 'apprehension', endeavouring to coerce the range to increase painlessly; that is, without apprehension being provoked. Very slow grade IV- movements are used which are sustained at the position of the point of the apprehension, and then functionally released. This is the passive movement aspect of the management. To this has to be added re-education of the muscular control of the movement.
Locked joint loose bodies Although the term 'locked joint' is not ideal, it does serve to differentiate such a disorder from other types of movement restriction. A particular movement(s) of a joint, when it is locked, is blocked from being able to be moved into a range by an obstacle 'in' the joint. The movement cannot be improved by stretching, as would be so if it were stiff. Something is obstructing
5. Sprains can be considered at two levels - those that
the movement. To improve or restore the movement,
cause partial ligament tears (e.g. sprained ankle),
the blocking object has to be moved out of its position.
and those that rupture a ligament (e.g. rupture of
Of course, if it can be moved out of its blocking pos
medial ligament of the knee):
ition it can also move back again; thus to mobilize and
(a) For the sprained ankle variety, as well as 'ice,
successfully free the movement passively is not neces
compression,
elevation',
passive
movement
sarily going to be a lasting success.
should be utilized. The movements should be
Loose bodies and menisci can be structures that can
slow, smooth, grade III-. All directions includ
block movement of a joint and to move them requires
ing all joints from the inferior tibiofibular joint to
specific techniques.
the interphaJangeal joints should be performed
The joint must be distracted or opened to allow
but the main emphasis should be placed on the
movement of the offending mechanical focus within the
'injuring movement'. It should be the first move
increased joint space. While the joint is opened on the
ment used in the routine and should be repeat
painful side it should be moved back and forth in direc
edly performed, being interspersed by the other
tions that will move the bones to which the loose piece
movements referred to. The 'injuring move
is attached. By continuing the movement or varying the
ment' should be extremely slowly taken to the
movements as dictated by progress, or lack of progress,
point where the 'hurt' begins and then held
the obstruction may be moved into a painless position,
there for some seconds before releasing - this is
allowing the joint movement to become free.
repeated at least four times hoping to be able to
Cyriax and Cyriax (1983) and Corrigan and Maitland (1983) discuss and describe techniques.
move gradually a little further into the range. If the available range increases well into the proce dure, during the holding phase of the technique, a tiny movement may be attempted to gain more movement. This extra added movement should not be held if the hurt increases markedly into a very painful range.
SELECTION AND PROGRESSION OF TECHN IQUES BASED ON DYSFUNCTION , MOVEMEN T IMPAIRMEN T AND COMPARABLE MOVEMENTS/I N J URING MOVEMEN TS
The session of 'injury movement' interspersed
6) of every
with general movements would take as long as
The aim of physical examination (Chapter
20 minutes. It should be repeated as a slow active
patient is to reveal one or more movements (both
home exercise movement in the elevated pos
active and passive) which are comparable with the
ition at intervals of 1-2 hours. Here it is important
patient's symptoms and where possible reproduce the
that the patient be taught how to monitor the
patient's symptoms.
effect of the movement so that an exacerbation is avoided.
Active functional movements demonstrated by the patient (functional demonstration) as being abnormal
The treatment for a complete rupture of the
or which caused the injury are always assessed in
medial ligament of the knee (referred to above),
terms of range/pain response /and quality. The amount
uses much the same as in (a). The aim is to
of range lost and the factors which cause this loss will
make the unstable abduction of the knee a large
determine what technique is used in terms of direction,
231
232
M A ITLA N D ' S P E R I P H E RA L M A N I P U LATI O N
[ grade, speed, rhythm and duration. For example, a behind the back, it is only possible to take the hand to
t'! .a
the hip because of severe pain in the shoulder. The
c
I
�
:0
directed at treating the pain at its source with gentle,
2 'f::
pain-free, small amplitude, slow, smooth, oscillatory accessory movements. Contrast this with the patient
.2:-
Q) (f)
joint. The technique required for this patient's dys
A
function should include physiological and accessory
When a comparable passive movement is found,
Y2
.� >
minor discomfort in the right temporomandibular
a movement diagram (Appendix
P' (local intense)
Y2
'T
who cannot open the mouth fully due to stiffness and
the mouth opening movement.
0
'"
choice of treatment technique, therefore, should be
small amplitude stretching techniques at the limit of
R2 (IV+++)
C
patient may demonstrate that, in trying to put a hand
Figure 8.83 abduction.
R1 v..
P1
%L
B
(local) Range Group 4: knee full flexion, medial rotation and
1) is used to qualify
the extent of the movement restriction and the factors limiting the movement. If this examination of passive movement is carried out with care and detail the movement diagram can be a valuable tool to classify ing the patient's movement impairment into one of the clinical groups described earlier and therefore guide the selection and progression of techniques: •
the diagram of a comparable movement for a patient from group
1 would show that it is pain that 60% of normal
limits active movement to less than (see Fig. •
8.12)
a patient in group
2 would have movements repre 8.13 where it can be seen that
sented as in Figure
movement is limited and that pain is absent or minimal •
•
although patients in group 3 vary widely, the impor
The treatment movement is depicted by a double
tant fact is that, as the severity of the pain increases,
headed arrow directed horizontally. The amplitude of
the strength of the resistance also increases (Figs
the movement is depicted by the length of the arrow
8.14, 8.15)
and the position in the range is depicted by relating the
finding a movement comparable in group
4 is
sometimes very difficult. Frequently only one com parable movement can be found. Sometimes physi ological movements are normal and it is only when accessory movements are tested in combination with physiological movements that a comparable movement is found.
8.84 represents a treatment tech 20° amplitude movement performed 30° short
performed. Figure nique of
of full elbow extension. One or all movements of a painful, stiff and painful, or stiff painless joint may be used in equal and varying degrees. The treatment technique applied to such joint
For example, a patient with minor knee symptoms may have a full painless range of all physiological knee movements. When full flexion is combined with medial rotation and abduction, however, pain is elicited and the movement is found to be stiff. This therefore is the comparable movement (Fig.
arrow to the AB base line representing the range or direction of movement into which the technique will be
8.83).
Furthermore, the amplitu.de and position in range
disorders should be considered from two aspects: 1.
which movement should be used to best achieve the desired effects
2. how should the movement be performed with reference to its amplitude, rhythm and position in the range in order to fulfil this requirement.
can then be depicted on the movement diagram in its
This choice will primarily be affected by the joint
appropriate place in relation to how much pain is to be
affected, the symptoms and signs and the pathology,
provoked or how far into resistance it should carry.
as has already been highlighted.
Pri nci ples of selection and progression of mobil ization / ma n i pu lation tech n iques
SELECTION AN D PROGRESSION OF TECH NIQU ES I N FLUENCED BY PRECAUTION S AN D CON TRAIN DICATIONS TO TREATMEN T Chapter 7 details the factors which will be precautions and contraindications to treatment by passive move ment (mobilization/manipulation).
Between the third or fourth treatment session and the final analytical assessment, the manipulative physio therapist should be able to answer the following questions about a patient's disorder in the quest for a prognosis: •
•
Factors which may influence the expected rate and extent of recovery (contributing factors and barriers to recovery) Most movement-related neuromusculoskeletal disorders have a natural history, fairly predictable rates of recovery and predictable responses to treatment using pass�ve mobilization treatment techniques (e.g. frozen shoulder, knee ligament sprains, episodes of symptoms related to overuse of osteoarthritic joints). The challenge for the manipulative physiotherapist, however, is to establish why a disorder is not recovering and respond ing to treatment in a way that would be expected for that particular disorder. TI1ere may be a number of rea sons why a patient's pain, stiffness, spasm, weakness, etc. are recovering slower than expected or that a point is reached where there is no further improvement. These factors will need to be identified by in-depth questioning, retrospective assessment (Chapter 5) and further detailed examination. Any barriers to recovery should then be dealt with, if possible, either in conjunc tion with treatment of the evident joint signs or sep arately before returning to treating the joint signs. These barriers to recovery will influence the way treatment is selected and progressed according to the guidelines proposed for each of the clinical groups 1, 2, 3a, 3b, 4 and associated signs. Figure 8.85 represents a model of how contributing factors can influence the natural his tory of the disorder and how barriers to recovery can interfere with the ideal progression of treatment of movement-related joint signs.
•
•
•
•
•
•
•
A generalized prognosis can be made by answering these questions in cases of recognizable patterns and reCOgnizable pathology. Specific hypothesis categories should also be considered to enhance the prognosis, as follows: •
•
The influence of prognosis on the selection and progression of treatment 'Prognosis is the forecast of the probable course of a case of disease or injury, or it is the art of making such a forecast' (Short Oxford Dictionary 1980). Jeffreys (1991) informs us that 'prognosis . . . is an art, or a skill, not a science. It concerns probabilities not certainties and it refers to the individual not the gen eral . . . Fortunately, although individuals differ in their response to insult, their ailments follow recognizable patterns and it is possible to form general predictions of the natural history of disorders.'
What is the diagnOSis and what pathobiological mechanisms are involved? What is the source or cause of the source of the patient's symptoms? To what extent is movement impaired and function limited by the symptoms? To what extent is severity or irritability of symptoms limiting movement and activity? What predictions can be made about the natural history of the disorder based on its onset, stage of pathological development and pathological stability/lability? What predisposing factors are influencing the course of the disorder (pre-existing pathology, weak link, the nature and extent of injury, age related processes, general health state, physique, occupation, genetic predisposition, etc.)? What factors are contributing to a favourable or unfavourable prognosis? Is the disorder one that will be easy or difficult to help based on the examination and response to treatment? What do we understand about the patient's nature and response to injury and illness (adaptive/ maladaptive behaviour)?
•
•
disorders which are easy or difficult to help (e.g. complex region pain syndromes) the nature of the person (stoic, excessive complainer, pain tolerance, hostility towards the medical profeSSions, ethnic/social group, genetic components, slow healers, expectations of treatment, psychosocial 'yellow flags') the nature of the disorder (intra-/periarticular disorders, mechanical osteoarthritis/inflammatory osteoarthritis, acute injury/chronic degenerative, nociception alone/nociception with peripheral neurogenic or central sensitization) the body's capacity to inform and adapt (the way the patient 'feels' about their disorder often correlates well with the other prognosis hypothesiS categories - for example, 'I've had
233
234
M A ITLA N D ' S P E R I P H E RA L M A N I PU LAT I O N
[
A model of pRIgnISIIon of mobIIIzaIIanImI • • •
The ideal road to rac:overy - tissue based FaclorB diverting Ideal racovery bIopsychoaociaI The journey can begin at any point depending on the present stage of the disorder In lis naIInI history -
A to B Is the Ideal road to racovery (e.g. a sprained ankle from lis lraUmatic origin to lis resolution )
Ideal road to recovery (A to 8) - tissue based The role of mobilization/manipulation Clinical groupings
Factors which may divert ideal recovery and which will need addressing along the way A (Onset)
• •
Group 1 •
Accessory I II •
Group 3a
Contributing factors
•
Previous injury Established pathology Medical conditions, e.g. diabetes
Group 3b
Accessory and physiological III I At limit, respecting pain •
Combined accessory and physiological at limit into 'bite' of pain (IV)
•
The cause of the source
Alignment faults Stiffness in joints above and below Ergonomics
Group 2 •
The nature of the person
Unrealistic expectations for recovery Return to activities too soon Fear avoidance Slow healer •
Figure 8.85
Potential barriers to full recovery
Chronicity Pathology Other yellow flags Anomalies/Structural impairments
A model of progression of mobilizati o n / manipulation.
knee pain for 20 years so I know I'll never totally •
Other components
Neurodynamic mechanosensitivity Muscle length/Strength changes
Group 4
8 (Resolved)
Other pain mechanisms
Neurogenic inflammation/ maintained sympathetic output
Accessory II Physiological II
Accessory and physiological at limit (IV) Manipulation
Psychosocial yellow flags
Unhelpful thoughts, behaviours
In summary, prognosis is a forecast of thefuture history
get rid of it.')
of a patient's disorder based on the probability of
contributing factors and other barriers to
physical, psychological and functional recovery of
recovery (structural anomalies, systemic d isease,
the patient and the disorder. Therefore consideration
general health problems such as diabetes,
should be given to:
ergonomic/socioeconomic en vironmen ts such as keyboard workers, heavy manual work, low income) •
expertise of the physiotherapist, especially in the fields of communication and handling.
1.
the natural history of a particular disorder - is the disorder running its course?
2. the response to manipulative physiotherapy treatment - has the progress been acceptable?
Pri nciples of selection and progression of mobil ization / manipulation techniques
�
, lid The basis ,'" � � �·I
Box 8.2 • • • • • •
•
3. what is acceptable to the patient - has the main
.'
Signs/sym ptoms (cl in ical g roupings) Com parable movements (dysfunction) Sou rce of symptoms (cause of the sou rce) Stage in natu ral history Pathobiological mechan isms Contributing factors, precautions and contra indications, barriers to recovery Prognosis
problem been solved?
4. is there need for prophylaxis - is a home programme needed to complement or maintain recovery; is 'top-up' treatment required periodically?
5. prognosis should at all times be realistic. Box
8.2 outlines the basis of selection and progression
using hypothesis categories.
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Charnley, J. 1973. Communication to a symposium on biomechanics, Institution of Mechanical Engineers, London 1959. In Gray's Anatomy, 35th edn., p. 193. London: Longman Clarke, 1. C. 1975. Friction and wear of articular cartilage a pendulum/SES system. Journal of Bone and Joint Surgery, 57A, 567 Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Medicine. London: Butterworths, pp. 78-149 Cyriax, J. H. & Cyriax, P. J. 1983. Illustrated Manual of Orthopaedic Medicine. London: Butterworths, pp. 51-98 Delbet, 1. C. 1950. Cited by Platt, H. Orthopaedics in Continental Europe 1900-1950. Journal of Bone and Joint Surgery, 32B, 574-584 Ekholm, R 1955. Nutrition of articular cartilage. Acta Anatomica, 12, 77
Evans, P. 1998. Ageing, degeneration and trauma in joints. Physiotherapy, 84, 564-565 Flint, M. H. 1976. The role of environmental factors in connective tissue ultrastructure. In The Ultrastructure of Collagen, pp. 60-66. Springfield, IL: C. C . Thomas Frank, c., Akeson, W. H., Woo, S. L-Y. et al. 1984. Physiological and therapeutic value of passive motion. Clinical Orthopaedics and Related Research, 185, 113-125 Gebhard, J. S., Kabo, J. M. & Meals, R A. 1993. Passive motion: the dosage effects on joint stiffness, muscle mass, bone density and regional swelling. Journal of Bone and Joint Surgery, 75A, 1636-1647 Gifford, 1. S. 1997. Pain. In Rehabilitation of Movement: Theoretical Basis of Clin ical Practice, ed. J. Pitt-Brooke. London: W. B. Saunders Gifford, 1., ed. 1998. The mature organism model. In Topical Issues in Pain - Whiplash: Science and Management. Fear Avoidance Beliefs and Behaviour. Adelaide: NOI Group
Gillard, G. c., Merrilees, M. J., Bell-Booth, P. G. et al. 1977. The proteoglycan content and the axial periodicity of collagen in tendon. Biochemistry Journal, 163, 145-151 Hassler, C. R, Rybicki, E. E, Diegle, R B. & Clark, 1. C. 1979. Studies to enhanced bone healing via electrical stimuli. Clinical Orthopaedics and Related Research, 124, 9-11 Higgs, J. & Jones, M. A. 2000. Clinical Reasoning in the Health Professions, 2nd edn. New York: Butterworth-Heinemann Hunter, G. 1994. Specific soft tissue mobilization in the treatment of soft tissue lesions. Physiotherapy, 80, 15-21 Hunziker, E. B. 2002. Articular cartilage repair; basic science and clinical prospects. Osteoarthritis and Cartilage, 10, 432-463 Jeffreys, E. 1991. Prognosis in Musculoskeletal Injury: A Handbook for Doctors and LaWl)ers. London: Butterworth Heinemann Jull, G. 1979. The role of passive mobilization in the immediate management of the fractured neck of humerus. Australian Journal of Physiotherapy, 25, 107-114 Lowther, D. A. 1979. The Effects of Compression and Tension on the Behaviour of Connective Tissue in Aspects of
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[ Manipulative Therapy, Melbourne: Lincoln Institute of
Health Sciences, pp. 15-21 Lowther, D. A. 1983. Unpublished observation. Maitland, G. D. 1978. Demonstration of patient I: shoulder manipulation (50 mins), and Demonstration of patients II and III (55 mins). Videotape numbers 17 and 18. Postgraduate Teaching Centre Hermitage, Medizinische Abteilung, Bad Ragaz, Switzerland CH 7310 Maitland, G. D. 1985a. The hypothesis of adding compression when examining and treating synovial joints. Journal of Orthopaedic and Sports Physical Therapy, 2, 7-14 Maitland, G. D. 1985b. Passive movement techniques for intra-articular and periarticular disorders. Australian Journal of Physiotherapy, 31, 3-8 Maitland, G. D. 1991. Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann Maitland, G. D., Hengeveld, E., Banks, K. & English, K., eds. 2001. Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Malcolm, L. L., Fung, Y. c., Woo, S. L-Y. et al. 1975. Steady state dynamic friction properties of cartilage - cartilage interfaces. Journal of Bone and Joint Surgery, 57A, 567 Maroudas, A., Bullough, P., Swanson, S. A. V. & Freeman, M. A. R. 1968. The permeability of articular cartilage. Journal of Bone and Joint Surgery, SOB, 166-177 McDevitt, C. & Muir, H. 1977. An experimental model of osteoarthritis: early morphological and biochemical changes. Journal of Bone and Joint Surgenj, 59B, 24-35 McNair, J. & Maitland, G. D. 1983. The role of passive mobilization in the treatment of a non-uniting fracture site - a case study. International Conference on Manipulation Therapy, Manipulative Therapists Association of Australia Mow, Van C. & Kuei, C. K. 1975. The effect of visco-elasticity on the squeeze film action of lubrication of synovial joints. Journal of Bone and Joint Surgery, 57A, 567 Noel, G., Verbruggen, A., Barbaix, E. & Duquet, W. 2000. Adding compression to mobilization in a rehabilitation
programme after knee surgery: a preliminary clinical observational study, Manual Therapy, S, 102-107 Panjabi, M. M., White, A. A. & Wolf, W. W. Jr. 1979. A biochemical comparison of the effects of constant and cyclic compression on fracture healing in rabbit long bones. Acta Orthopaedica Scandinavica, 50, 653-661 Peacock, E. E. & Van Winkle, W. 1976. Wound Repair, 2nd edn. Philadelphia: W. B. Saunders Reichmister, J. P. & Freidman, S. L. 1999. Long term functional results after manipulation of the frozen shoulder. Maryland Medical journal, 48, 7-11 Salter, R. B. 1982. Presidential address. journal of Bone and Joint Surgery, 64B, 251-254 Salter, R. B. 1985. Motion versus Rest: Why Immobilize joints? Proceedings of the Manipulative Therapists Association of Australia, Brisbane, pp. 1-11 Salter, R. B., Simmonds, D. E, Malcolm, B. W. et al. 1975. The effects of continuous passive motion on the healing of articular cartilage defects - an experimental investigation on rabbits. Journal of Bone and Joint Surgery, 57A, 570-571 Salter, R. B., Simmonds, D. E, Malcolm, B. W. et al. 1980. The biological effects of continuous passive motion on the healing of full-thickness defects in articular cartilage. journal of Bone and Joint Surgery, 62A, 1 232-1251 Shorter Oxford Dictionary. 1980. Shorter Oxford Dictionanj on Historical Principles, 3rd edn. Oxford: Oxford University Press Thomas, H. O. 1950. Cited by Osmond-Clarke, H. Half a century of orthopaedic progress in Great Britain. Journal of Bone and joint Surgery, 32B, 622-623 Van Wingerden, B. A. M. 1995. Connective Tissue in Rehabilitation. Vaduz: Scirpo Verlag Williams, J. G. P. & Sperryn, P. M., eds. 1976. Sports Medicine. London: Edward Arnold, pp. 441- 586 Williams, P. L. & Warwick, R. 1980. Gray's Anatomy, 36th edn. Edinburgh: Churchill Livingstone Yasuda, 1. 1997. The classic-fundamental aspects of fracture treatment. Clinical Orthopaedics and Related Research, 124, 5-9
237
Chapter
9
Recording
THIS CHAPTER INCLUDES: •
Key words for this chapter
•
Glossary of terms for this chapter
•
Recording principles
•
Recording examples for various stages of the physiotherapy process.
KEY WORDS Recording, reassessment, SOAP notes.
GLOSSARY OF TERMS SOAP notes - recording of therapy sessions must include detailed information, yet must be brief and provide a simple overview. Within this concept use has been made of
the so-called 'SOAP' notes (Weed
1964,
Kirk
1988). The acronym
SOAP refers to the various parts of the assessment process:
1.
Collection of �ubjective information
INTRODUCTION
Assessment and treatment require an in-depth written record of the findings and results at each session. Ideally, documentation which is systematic, consequent and easy to (re-)read in a short time provides the physio therapist with a framework that should lead the therapist throughout the overall therapeutic process. Systematic records serve as a mnemonic and a means of communication to other professionals. They sup port the physiotherapist in various ways: • • •
to reflect upon the decisions made to control the actions taken if necessary, to quickly adapt the therapy to a changing situation.
2. Collection of Qbjective information
3. Performing an gssessment
4.
Develop and formulate a p-Ian
POMR - problem oriented medical records, containing SOAP acronym.
Hence, written records are essential in the process of ongoing quality management. It is argued that many physiotherapists consider documentation of sessions as a necessary evil. As a consequence many records frequently seem superficial and incomplete (Cohen 1997). Although probably recording will not be encountered with a lot of positive expectations in learning the 'art of physiotherapy', there are various reasons why physiotherapists should consider the recording of the sessions they shape: •
Records serve as a mnemonic for the physiother apist of what has been done, thought and planned.
•
Systematic recording serves clinical reasoning and learning processes: committing thoughts to paper
238
MAITLAND'S PERIPHERAL MANIPULATION
•
forces therapists to think more precisely and accur ately and to become aware of their own reasoning processes. It enhances reflection and monitoring decisions made and actions taken.
overview. Within this concept use has been made of the so-called 'SOAP' notes (Weed 1964; Kirk 1988). The acronym SOAP refers to the various parts of the assessment process:
Committing the essence of examination and treat ment findings to paper is a valuable learning expe rience in itself. It forces one to identify the things that are essential, and record them, and leave out the less important information.
Collection of subjective information Collection of objective information 3. Performing an assessment 4. Develop and formulate a plan.
•
Committing thoughts to paper, with systematic recording, helps to clear the mind as the information and impressions gained throughout are organized.
•
Recording of patient information, actions and plan ning steps support the development of clinical patterns in memory. Therefore recording may be an essential process in the development of experiential knowledge (Higgs & Titchen 1995, Nonaka & Takeuchi 1995).
•
Ideally, the records should document the trail along which assessment and treatment are moving.
•
Comprehensive, systematic patient records may serve as a basis for clinical case studies.
•
Records may be a mnemonic for the patient as well. In some cases, the patient may have forgotten how the disorder has been improved immediately fol lowing a treatment. If for other reasons a few days later the symptoms recur, the patient may easily interpret the condition as unchanged. Examination of the record made immediately following the treat ment may guide the physiotherapist as well as the patient in the reassessment of the patient's condition over the whole period directly after the last session until the moment that symptoms increased again.
•
Records aid communication in team collaboration. If a colleague is absent from work, the physiother apist may be able to continue with the initialized course of treatment, provided the records are such that they are understandable.
•
Recording for legal reasons - in many countries phys iotherapists are enforced by law to store their patient records for a certain period of time. Furthermore, physiotherapy records may be used in litigation.
•
An increasing number of professional associations declare documentation as an integral part of the physiotherapy process (OPV 1998, WCPT 1999, Heerkens et al 2003).
SOAP notes
Recording of therapy sessions must include detailed information, yet must be brief and provide a simple
1.
2.
It is not mandatory to follow the guidelines and abbre viations as set out in this book; however, some method must be determined to suit the patient's comments and the therapist's pattern of thinking. The basic elem ents of the SOAP mnemonic may serve as a useful format to follow all the steps of the therapeutic process in a brief and comprehensive way. It has been argued that the term 'objective' in the SOAP notes is somewhat awkward, due to the fact that the physiotherapist values the subjective experience of the patient while performing the test movements. Furthermore, it is argued that the physiotherapist as the 'measuring instrument' will give attention to those aspects of a test which seem most relevant at the time, and thus true objectivity in test procedures may not exist (Grieve 1988). It has therefore been decided to replace the term 'objective examination' with 'physical examin ation' (PIE). There has been criticism that SOAP notes within problem oriented medical records (POMR) would con fine the physiotherapist to focusing merely on biomed ical data (French 1991); however, if the physiotherapist pays attention to key words and specific key phrases of the patient which are indicative of the individual ill ness experience, they may be recorded in parentheses and integrated in the documentation, thereby incorpor ating elements of the individual illness experience into the records. At all times patient records should include the find ings as well as the steps in planning - a trail is laid of what is done and what is thought. Recording encom passes ideally: •
• • •
information on examination and assessment procedures treatment interventions and results (reassessments) planning steps and hypotheses formulated important key words or phrases of the patient.
ASTERISKS
During the subjective examination the patient may state certain facts related to the disability which may prove to be valuable parameters for reassessment procedures.
Recording
Box 9.1
Use of asterisks
conditions need to be fulfilled. Patient records need to be: •
Asterisks are an invaluable aid in assessment
•
procedures. The use of an asterisk in recording
•
highlights the following aspects:
• •
•
Primary symptoms or activity limitations
•
Signs that reproduce a patient's symptoms
•
Other important comparable signs that will be
•
Other information that is important
followed up in reassessment procedures •
Key issues that need to be followed up
•
'Asterisk as you go along' indicates that it is important to immediately highlight relevant findings once they have been obtained rather than in retrospect. If the findings have been recorded straight away it will influence the physiotherapist in the further procedures of examination and assessment.
These should be highlighted in the records immediateLy, and an 'asterisk' sign may be used. Although the use of asterisks is not mandatory, it may speed up the whole process. They are time savers, reminders and indicators of highly important facts for the particular person. Identifying these main assess ment markers with a large, obvious asterisk not only enforces a commitment but also makes reassessment procedures quicker, easier, more complete and there fore more valuable. Using asterisks is just as valuable for the physical examination parameters as it is for the subjective exam ination. Similarly, making use of the asterisks progres sively during the physical examination rather than after is recommended. The same applies to each subsequent session. At times it seems that the term 'asterisk' has become jargon; however, it is not meant in such a way. People teaching and working with this concept may frequently use the term 'subjective and physical examination aster isks'. Mostly this refers to information of subjective and physical examination parameters which will be reassessed at regular intervals over the whole thera peutic process in order to monitor progress in rehabili tation and the effects of treatment (Box. 9.1).
CONDITIONS
Some people may prefer other ways of recording. However, regardless the method of recording, some
•
organized clear comprehensive simple to (re)read written concisely, in telegraphese homogenous, consequent.
SOME REMARKS WITH REGARDS TO RECORDING
It is important to record related information even when the findings indicate normality. By their having been recorded, reference at a later date shows that the par ticular questions have been asked or physical examin ation tests have been carried out. Recording normal findings on a 'record sheet' is a quick and simple procedure. For example, if a patient has pain in the shoulder area and the therapist has examined the acromioclavicular joint comprehensively and found it to have normal painless movements, all that might be recorded is: Ale.l.I. The point is, it must be recorded. There is much more to be recorded from an initial consultation than for subsequent sessions. However, the same detail is required and so the same details and abbreviations can be used. People have likes and dis likes about these symbols - this does not matter, pro vided the criteria for comprehensive recording are met. Questionnaires as well as 'cheat sheets' as they are often termed, have advantages and disadvantages. The primary considerations are that they should not be regimented and they should not be detailed. A cheat sheet that has a list of questions requiring ticks and crosses, should not be used. They are inflexible and destroy independent thinking on the part of the exam iner, and they completely obliterate any chance of fol lowing the patient's line of thought or the pursuit of hypotheses in greater detail.
RECORDING OF SUBJECTIVE EXAMINATION FINDINGS
With each patient there are many questions and answers that need to be entered in the recording, even if it is only to show that the question, which was important, has in fact been posed and answered. It is a safe procedure to utilize the patient's words during the recording of subjective examination findings. For example, if a patient complainS of a pulling in the
239
240
MAITLAND'S PERIPHERAL MANIPULATION
2
CD @ Always together CD if CD ++ @ No relation
Figure 9.1
Example of a body chart.
arm while lifting the arm above the head, this needs to be recorded as the patient said it, rather than the physiotherapist's language of 'symptoms or pain with flexion', as this may immediately narrow down the physiotherapist's thinking. Key words and phrases indicative of the personal illness experience may be put in quotation marks. It has been emphasized that such key words and phrases may be essential information to the shaping of the therapeutic process, hence they have to be recorded accordingly. Organization of the information in the main cat egories of the subjective examination is essential to keep an overview over the process of subjective examin ation. While asking questions regarding the 'main pro blem', it is possible that the patient gives information on history mingled with, for example, bits of symptom atic behaviour. In such cases it is relevant to leave suf ficient space on the paper to organize and record the information under sections 'history' or 'behaviour'
rather than writing down every bit of information in a chronological manner. This will help the physiother apist to keep an overview over the whole process of subjective examination, even if the communication technique of 'paralleling' has been chosen (Chapter 3).
Body chart •
Frequently, after establishment of the patient's main problem and receiving a more general statement about the perceived disability, the area, depth and nature, behaviour and chronology of the symptoms are clarified and recorded on a 'body chart' (Fig. 9.1).
•
Reference to such a body chart provides a quick and clear reminder of the patient's symptoms and main problem.
•
A well-drawn body chart helps to generate hypoth eses on the sources of the movement dysfunction or
Recording
Current
I
I
Hx
� Since when
� Since 4 weeks
I
I
I
I Details on onset of symptoms
�
•
•
•
�
J
Same. Does not bother DLA much
Could continue judo training
No medic., or other Rx
I
I Now: onset
1
I
8
Went to GP because 'annoying'
GP-+PT
Time line: current history.
symptoms as well as on the neurophysiological pain mechanisms. Additionally, first hypotheses with regard to precautions and contraindications may be made. •
I
I Progression since onset
Judo: fall on side -little pulling, groin Sy.G) little bit day 1, over c. 7 days difficulties twith gardening, judo, stiffness a.m.
Figure 9.2
I
In principle, the body chart is drawn by the physio therapist to facilitate recording and memory.
OccaSionally, in patients with chronic pain states, the body chart may be drawn by the patient. If dif ferent colours are used, as a metaphor for the pain experience they may become a guide in reassess ment procedures. If the information on a body chart is recorded con sistently at the same place all the time, self-monitoring mechanisms are more easily activated. If the physio therapist forgets to ask certain questions, this may be noticed more easily when re-reading the information. The use of Arabic numerals in circles for the differ ent symptom areas simplifies later recording: if there is a need to refer to the symptom areas, the numerals can be used rather than lengthy descrip tions of the symptom areas.
Always record the same information on the same spot of the body chart. This enhances self-monitoring - on re-reading the information it will be easier to discern if certain details are missing.
Behaviour of symptoms and activities
As described in Chapter 6, the information on the 'behaviour of symptoms' is essential to the expression of many hypotheses. Furthermore, the information usually serves in reassessment procedures of subse quent sessions. Therefore the information needs to be recorded in sufficient detail.
If activities or positions are found which aggravate the patient's symptoms, this has to be recorded meticu lously. However, any easing factors also need to be writ ten down straight away, on the same line as the activity which provokes the symptoms. This may sound pedan tic to some; however, it will give the physiotherapist an immediate overview as to which activities and positions the patient has developed as useful coping strategies and with which ones the patient may need some help. Some examples are:
* CD i
* CD * CD
Gardenin g, pulling weeds, in squat position; after 10' PI CD, after 20' CD+ � Gets up, walks around (few steps, shuttles leg): CD� 100% immed. May continue gardenin g. i Putting on socks, in standing - activity possible as usual � CD � 100% immed. as soon as leg is put down. i Lying in bed - prone, right leg pulled up. Wakes up c. 03:00 CD+ � Does not know how to ease. Gets up, walks c. 20' CD 'acceptable'
History
At times it may be difficult to keep an overview of all the information regarding the history of a patient's problem and to monitor if all the relevant data have been obtained. This may happen particularly in those circumstances where there have been more episodes and the problem has been recurrent for many years. Although not mandatory, the physiotherapist may draw a line indicative of the course of time to keep an overview of both the current and previous history (Figs 9.2, 9.3). RECORDING O F PHYSICAL EXAMINATION FINDINGS
Physical examination findings need to be recorded in sufficient detail and systematically in order to allow
241
[
242
MAITLAND'S PERIPHERAL MANIPULATION
Previous Hx
I
1995 - after marathon
- after c. 1 week gone
I
I
2000
� �
I
2002
I
2003
- after judo championship
- gone after 1 week
� �
2004 - after judo training (current Hx)
Between episodes: no symptoms, no disabilities Current episode: does not disappear with little stretching exercises as in other episodes
Figure 9.3
Tim e line: previous hist o ry.
for quick referencing during subsequent reassessment procedures. Making use of symbols helps speed up the process and enhances quick referencing (Table 9.1).
ACTIVE MOVEMENTS
When recording the range and quality of movement and the symptomatic response to that movement, one should develop a pattern of recording and stick to it. By doing so, more facts can be remembered, while at the same time leaving the therapist's mental processes more time to take in other details. Active movement findings can be recorded as follows:
This indicates that the range of abduction has been 170°, with a deviation of the movement between 120° and 170° of abduction; symptom reproduction occurred at the active end of range without application of over pressure. With correction of the deviation in the move ment, the range decreased until 130° of abduction and the pain was clearly increased. *
Hip F 130°, loc P groinrv_, CDrv+
This example shows that the overall range of hip flex ion was 130°, without any deviations in the quality of the movement; local symptoms were produced with a light overpressure ('IV-'), symptom reproduction occurred with stronger overpressure ('IV+'). PASSIVE MOVEMENTS
This example means supination (sup) has a normal range and quality of movement (the first tick, ./) and has no abnormal pain response when overpressure is applied (the second tick, ./). It is suggested relating the first tick (./) to move ment responses such as range and quality of move ment and the second tick (./) to symptom responses which occur during the test movement. It may be indi cated with a grading of IV -, IV or IV+ how firm the overpressure has been. This is particularly relevant in those cases where the phYSiotherapist wants to test the movements with a certain amount of overpressure; however, factors in the 'nature of the disorder' (Chapter 5) may limit the phYSiotherapist in applying maximum overpressure. A movement cannot be classed (or recorded) as nor mal unless the range is pain free both actively and pas sively. Further overpressure applied at the limit of the available range should not cause pain other than nor mal responses. Abnormal findings may be recorded as follows: *
Ab 170°, Dev. Ventr. 120--- 170°, CD act. EOR Corr. Dev. 130°, CD++
With passive movement the behaviour of pain, resist ance and motor responses (spasm) is monitored. The physiotherapist is particularly interested in how these components behave and relate to each other. This is a very detailed examination procedure and may be con sidered as a part of the 'art of manipulative physio therapy'. Most simply, but not mandatory, would be the drawing of a movement diagram, as delineated in Chapter 7 and Appendix 1. Otherwise abnormal find ings regarding the behaviour of P1 and P', Rj and R2, including their relationship, may be recorded verbally. If certain passive movements are classed as normal, the same method (./,./) as with active movements may be used. However, if relevant abnormal findings are present, this method is not suffiCiently comprehensive.
Example: SLR ®: Rj: 50°, L R2 70°; Pj pulling hamstr. c. 55°, P' only little (3/10). =
This example indicates that the physiotherapist first felt an increase in resistance with c. 50° of SLR, the movement was limited by resistance at c. 70° of SLR, only a little pulling sensation was provoked in the hamstrings area. Figure 9.4 illustrates the associated movement diagram.
Recording
Totally e. 6' 'Comfortable'; after 4' R} to L, especially with I After c. 6' no further changes in P or R
RECORDING OF TREATMENT INTERVENTIONS
Before performing a treatment technique, the planning and the reasoning for its selection should be recorded. Next, the treatment and its effect should be written down. This needs to include sufficient details in order to be able to refer back at later stages when making ret rospective assessments. The treatment record for a passive mobilization technique should contain: • • •
• • • •
•
the position of the patient ' the position of the joint selected treatment technique(s), including inclinations of the movements grade(s) of the technique rhythm in which the technique was performed duration (in number of repetitions or time units) symptomatic responses and the patient's reactions while the intervention is being performed ('assessment during treatment' - see Chapter 5) reassessment immediately following the technique (it is usually helpful to make comparisons or statements as to which parameters have improved and which ones have stayed unchanged).
It is essential not only to record the treatment by pas sive movement in detail but also active procedures, exercises or physical applications (e.g. ultrasound requires the same depth of recording). Treatment is followed by a reassessment in which patients are asked to make a comparison of any changes of symptoms or in their sense of wellbeing resulting from the technique. This is then followed by a reassessment of the affected physical examination tests. Ideally, the records of the physical examination find ings include a brief appraisal of the results in comparison with the assessment just before the application of the treatment technique. Finally, at the end of a treatment session, the clini cian should commit to paper thoughts on how treat ment needs to be modified at the next session. Such an analysis not only forces the clinician to reflect on clini cal reasoning processes, but also stimulates memory of the last treatment session.
•
Other forms of treatment: In
sitting: do F/Ad hip R and L 5x, e. 10", until slight pulling buttock 'Comfortable'
•
C/O: 'same' P /E: F 160°, (1) IV ++ © ('feels much freer, I can move higher') HBB: range & P ISQ Plan: repea t same Rx;
Ultrasound
Sitting, knee extended Rx:US 3 MHz, large head; 1:2 int. 2 1.0 W /cm ; 3'; on tender spot, medially knee No pain
C/O: 'lighter than before to stand' PIE: Lx F: 2 cm, Lact EOR © Hip F: 130°, (1) IV+ © Plan: do ex. at/work; at least 3x/day A P buttock starts. 1-2 series; 5x/30" each leg C/O: 'not tender now' P /E: Squat: full range. L© E/AB: '/, (1) IV+ ©
(It is frequently useful to compare the results and to mark which elements may have improved following the intervention)
INFORMATION, INSTRUCTIONS, EXERCISES, WARNING AT TH E END OF A SESSION
Any information or instruction given during the treat ment, any exercise that the patient should perform as a self-management strategy needs to be recorded as well. At the beginning of a treatment series it is often important to warn the patient diplomatically for pos sible exacerbations. This also needs to be recorded.
Example •
Passive movement:
Rx G/H, Supine In: 150° F (before P1) Do: I, c: IV- to IV Smooth rhythm, reI. quick
Exercises
•
•
Examples:
if HBB remains ISQ, do ace. mvt in EOR HBB
•
Warned about possible increase; however, if spot gets smaller, may be a good sign. Should observe and compare: - mornings getting out of bed - changes in stiffness? - working in garden - anything different from before? - nights - anything changing in sleep pattern? - effect of exercise, if pain occurs? Instruction (e.g. remembers anything particular about fall during judo?).
243
N
t � » -i r » z o VI
Table 9.1
Recording symbols
.." m ::0
F
Flexion
E
Extension
Ab
Abduction
Ad
Adduction
:J �
Medial rotation
HF
Horizontal flexion Horizontal extension
HBB
Hand-behind-back
Inv
Inversion
Ev
Eversion
DF
Dorsiflexion
PF
Plantarflexion
Sup
Supination
Pron
Pronation
EI
Elevation
De
Depression
Protr
Protraction
Retr
Retraction
Med
Medial
Lat
Lateral
OP
Overpressure
PPIVM
Passive physiologicaI intervertebral movements Passive accessory intervertebral movements
ULNT
; t r
Lateral rotation
HE
PAIVM
.." ::c m ::0
Spine
Peripheral joints
Upper limb neural tests
Central posteroanterior pressure (PAs)
/ with a CD inclination
Central anteroposterior pressures (APs) Unilateral PAs on CD
< with a medial inclination
L
Unilateral APs on the CD
+--
Transverse movement towards CD
�
Rotation towa rds CD
'\
LateraI flexion towa rds
......
Longitudinal movement (state cephalad or caudad)
�
Unilateral PAs at angle of@ 2nd rib
� -t
CD
Further laterally on @on 2nd rib Unilateral APs on @
CT
/
Cervical traction in flexion
CT
t
Cervical traction in neutral (sitting)
IVCT
t
Sitting
IVCT /
Lying
IVCT /10 3/0 15
Intermittent variable cervical traction in some degree of neck flexion. the strength of pull being 10 kg with a 3-second hold period, no rest period, for a treatment time lasting 15 minutes
» r-
� » z .." C r » -i o Z
LLNT
Lower limb neural tests
LT
Q
Quadrant
LT 30/15
Lock
Locking position
F/Ab
Flexion abduction
F/Ad
Flexion adduction
E/Ab
Extension abduction
E/Ad
Extension adduction
Distr
Distraction
; t
Lumbar traction Lumbar traction, the strength of pull being 30 kg for a treatment time of 15 minutes Lumbar traction with hips and knees flexed:
LT crk 15/5
15 kg for 5 minutes IVLT 50 %
10
Intermittent variable lumbar traction, the strength of pull being 50 kg, with no hold period and no rest period, for a treatment time lasting 10 minutes
Posteroranterior movement Anteroposterior movement
......
Transverse movement in the
!
Gliding adjacent joint
direction indicated
>-+-
ro c
• •
I
�
•
P /E: additional tests as planned Plan: e.g. stick to plan as stated after Rx 2 Rx 3a (as above) .. . Rx 3b (as above) .. . Plan
:0
El Y2 :� I i?:' .� >
RETROSPECTIVE ASSESSMENT
Q) en
A
Y4
R, % P, L'Y. (locally hamstring-area)
B
Range
Figure 9.4
Movement diagram.
RECORDING OF FOLLOW-UP SESSIONS
When recording follow-up sessions, the first words must include a quotation of the patient's opinion of the effect of the previous treatment. This quotation must be worded in such a way that it is a 'comparison' rather than just a 'statement of fact' (Chapters 3 and 5). The subjective reassessment is then completed in which the physiotherapist clarifies those activities that serve as parameters and have been highlighted with an asterisk in the records of previous sessions. Following the subjective reassessment the record includes the physical examination tests which are being reassessed. These too are recorded as compari sons with the previous findings. Changes in the physical examination findings will hopefully agree with the findings of the subjective assessment, so reinforcing each other. This will then make the total assessment more reliable. Also during reassessment of physical examination tests it may be necessary to record key words and phrases; in the rehabilitation of, for example, shoulder problems it may be a good sign if the patient makes the spontaneous remark: 'the arm is mine again'. The following pattern may be used in recording follow-up sessions: •
•
•
Date, time of the day, Rx 3, DB (indicating third session on eighth day since the initial consultation) C/O spontaneous information: 'better', 'felt lighter than before' C/O follow-up of subjective parameter: putting on socks today cf. yesterday: no pain ( unusual! First time in 3 weeks!) PP P/E: reassessment of physical examination parameter (including statements of comparison with after/before the previous treatment)
The record of retrospective assessment has to stand out from other parts of the treatment so that the informa tion can be easily traced on reviewing progress in later sessions. This is particularly important when a patient has an extensive disorder and considerable treatment. To be practical, time must be a consideration, but not at the expense of detail and accuracy. Especially within retrospective assessment, in the written record three requirements should be respected: 1.
To stand out from other data (to be highlighted so that it is readily seen on checking back through the record). 2. To state with what time frame the comparison is made (e.g. Rx 5 cf. Rx 1). 3. To emphasize spontaneous information. Retrospective assessments should include the follow ing information and comparisons: •
•
• •
•
•
•
•
=
• •
•
General wellbeing compared with, for example, four sessions ago Symptoms compared with, for example, four sessions ago (know indicators of change - see Chapter 5) Level of activities compared Effect of interventions so far (P/E and passive movements) Effect of instructions, recommendations and exercises so far What has the patient learned so far -'what was particularly relevant to the patient? Comparison of all the relevant physical examination parameters compared with, for example, four sessions ago Which interventions brought which results? (certain physical examination findings may improve more with some interventions than with others) Goals for the following phases of treatment (process of collaborative goal setting: redefinition or confirmation of agreed goals to treatment, interventions and the parameters to measure if the objectives are being achieved).
Recording
WRITTEN RECORDS BY THE PATIENT
There are times when it is necessary for a patient to write a running commentary of the behaviour of the symptoms. For example, a patient may be a poor histor ian in which case he may be asked to write down how he feels immediately following treatment, how he feels that night and how he feels on first getting out of bed the next morning. Some people may feel this is encour aging a patient to become overly focussed on his symptoms. However, if the patient is asked not only to record how he feels, but also the level of activities, medication intake and possible self-management inter ventions, such a record may become a highly valuable teaching instrument which aids both the patient and the physiotherapist. There are many different types of pre-printed form that can be used. However, it is essential that the forms leave space for information regarding: • •
• •
symptoms activities before and during the increase of symptoms activities throughout the day /week employment of self-management strategies to influence wellbeing, including the effects of the interventions.
When a written record by the patient is used, it should be handled by the manipulative physiotherapist in a particular sequence: 1. On receiving it from the patient, it should be laid down. 2. The patient should be asked to give a general impression of the effect of the last treatment. 3. The subjective assessment of the effect of the last treatment should be taken through to its conclusion. 4. The written record can then be assessed and any discrepancies clarified. CONCLUSION
Although recording of examination findings, treat ment interventions and results, and regular planning, may not be the most interesting part of learning, it is an essential element of the quality of the overall therapeu tic process. It monitors the phYSiotherapist throughout the process and allows quick adaptation of interventions, if needed. When recording is accurate and succinct, and can be correctly interpreted by another person reading it, it is an invaluable self-teacher and may support physiotherapists on their path to expertise and main taining this.
References Cohen, L. 1997. Documentation. In Chronic Pain Management
for Physical Therapists, ed. H. Wittink & T. Hoskins Michel. Boston: Butterworth-Heinemann
French, S. 1991. Setting a record straight. Therapy Weekly, 1, 11
Kirk, D. 1988. Problem Orientated Medical Records: Guidelines for Therapists. London: Kings Fund Centre
Nonaka,1. & Takeuchi, H. 1995. The Knowledge-Creating Company. New York: Oxford University Press
Grieve, G. P. 1988. Critical examination and the SOAP
OPV 1998. Broschure Berufsbild Physiotherapeut. Vienna:
Heerkens, Y. F., Lakerveld-Hey, K., Verhoeven, A. L.
WCPT 1999. Description of Physical Therapy. London: World
mnemonic. Physiotherapy, 74, 97
J. et al.
2003. KNGF - Richtlijn Fysiotherapeutische Verslaglegging.
Amersfoort: KNGF
Higgs, J. & Titchen, A. 1995. The nature, generation and verification of knowledge. Physiotherapy, 81, 521-530
Osterreichischer PhysiotherapieVerband
Confederation of Physical Therapy
Weed, L. 1964. Medical records, medical education and
patient care. Irish Journal of Medical Science, 6, 271-282
247
249
Chapter
10
Peripheral neuromusculoskeletal disorders
THIS CHAPTER INCLUDES: •
Key words for this cha pter
•
Glossary of terms for this cha pter
•
An explanation and classification of neuro I musculoskeletal diso rders
•
How to recognize movement related and non-movement related disorders
•
The natural h istory of
•
neuro I muscul oskeletal disorders •
Typical syndromes and pathologies relevant to mani pulative
The structu res at fault and their
physiotherapy
c l i nical profiles
•
Clinical profi l ing
•
A review of mechanisms of
•
The art of prognosis ma king
symptom production
•
•
The c l inical significance of
Differential dia gnosis of systemic disease.
recognizing prima ry and secondary hyperal gesia
KEY WORDS
primary hyperalgesia, secondary
non-responders, prognosis,
Disorder, syndromes, mechanisms,
hyperalgesia, responders,
differential diagnosis.
brick wall, natural histo ry, structures,
GLOSSARY OF TERMS Abuse - a function or activity which results in physical abuse beyond reasonable limits. Affective mechanisms - cognitive mechanisms and emotional states which influence the p rocessing and u l timately the experience of pain and i llness. Allodynia - pain due to a stimulus that does not normally provoke pain, such as touch or movement. Barriers to recovery - factors which influence the natural history of a pa rticu l a r disorder such that recovery or the expected rate of recovery is affected. Barriers to recovery may include: fea r of
movement because of the pain
heaviness or the feeling of hot
experience; poor functional
water being poured down the a rm
sta bility once movement has been restored; medical conditions which slow down or p revent fu II recovery. Central sensitization - electrical and chemical events which take place in the processing of inputs to the central nervous system, such as nociception.
or leg. Hypermobility - a n excessive ra nge of movement (e.g. at the knee or elbow ) for which there is adequate muscu l a r cont ro l , thus providing stability. Instability - an excessive range of
In such instances, cells in the dorsal
abnormal movement for which
horn of the spinal cord, for example,
there is inadequate protective
become more sensitive to nociceptive barrages resulting in the triggering of pain states more easily or the enhancement of ongoing pain states. Disuse - due to laziness or after enforced rest. Dysaesthesia - an unpleasant but not painful sensation such as
muscular control. Misuse - a function or activity that is performed aw kwardly or in a silly way. Natural history - the recognizable and expected course of a pa rticular disorder from onset to recu rrence, ch ronicity or recovery and the
250
MAITLAND'S PERIPHERAL MANIPU LATION
[
expected rate of recovery of such a
such events. For some reason, in
or clinical diagnoses and typically
diso rder.
some cases, outflow is m a intained
respond in a predictable way to
after the event or perceived event,
manipulative physiotherapy
New use - some activity not performed previously or not
resulting in the perpetuation of the
(e.g. impingement, lateral
performed for a long time.
sympathetic response. This may
epicondylalgia).
Overuse - a limit to how far the body
lead to maintained pain states. Sympathetic outflow can be
of predisposing factors to the
brea king point.
measured indirectly t h rough, for
development of a pa inful
example, alterations in skin
neuromusculoskeletal disorder
Sympathetic outflow - activation of the sympathetic nervous system in response to noxious, injurious or
temperature and conductance. symptoms and signs which fall into
perception of the occurrence of
recognizable clinical presentations
This chapter provides a framework which will assist the manipulative physiotherapist in recognizing dis orders which will respond in known ways to passive movement treatment techniques. The aim of the chapter is to categorize the most common neuromusculoskeletal disorders treated by manipulative physiotherapists. The word disorder is used to cover any complaint from which any patient may suffer and be referred or refer themselves for physiotherapy. This includes disorders:
•
•
which can have an accurate diagnostic title/ recognizable pathology
•
which present as recognizable syndromes
•
whereby the physiotherapist may need to assist in differential diagnosis. For example, abdominal pains, chest pains, headaches and limb pains where it is not clear whether symptoms are originating from the neuromusculoskeletal system or from sys temic disease.
Neuromusculoskeletal disorders, therefore, can be classified as follows when deciding whether manipu lative physiotherapy should be considered as a treat ment option:
•
•
•
com binations.
potentially harmful events, or the
•
•
(strain or sprain). Often occur in
Syndrome - a collection of history,
INTRODUCTION
•
Use categories - a classification
can adapt. eventually reaching
Movement or non-movement related Natural histories (insidious, traumatic) Structures at fault (the clinical profile of articular, muscular, neural tissue disorder) Mechanisms of symptom production (primary and secondary hyperalgesia) Recognizable syndromes (their clinical profiles/pain patterns)
Prognosis (disorders which are easy /difficult to help) Differential diagnosis (clues to non neuromusculoskeletal disorders affecting the limbs).
MOVEMENT-RELATED AND NON-MOVEMENT-RELATED DISORDERS To
classify
neuromusculoskeletal
disorders
into
movement-related and non-movement-related complements the paradigm of physiotherapists as experts in move ment (Sahrmann 2001). For the manipulative physio therapist such classification is important in relation to scope of practice. In turn the clinician will then have evidence for the application of movement-related ther apies and will be able to gauge expected outcomes in relation to such therapies (Box 10.1).
Movement-related disorders A movement-related disorder can be defined as: 'any complaint which any patient may suffer and which has
Movement related •
Movements impa ired
•
Physiological! accesso ry! com bined
Non-movement related •
Symptoms not influenced by movement
Peripheral neuromusculoskeletal disorders
some relationshlp to movement (activity limitation due to movement impairment) at some stage during its nat ural hlstory'. Thls includes the quality and/ or quantity of functional movement or functional positions being affected by pain, stiffness, spasm and weakness, as well as associated movement-related impairments such as fear of movement or loss in trust of movement, paraes thesia, anaesthesia, dizziness, etc. Manipulative physiotherapists using thls (and other) concepts have the ability to identify and deal with movement-related disorders through the clinical decision-making process, specifically through the use of the brick wall concept (Chapter 1) and through the assessment process (Chapter 5). Both the theoretical and the clinical side of the brick wall can be utilized in detail to identify movement related disorders. Conversely, the same categories can be used to differentially diagnose disorders which often mimic neuromusculoskeletal disorders (symp toms in the spine or limbs) but whose symptoms bear little or no relationship to movement and neuromus culoskeletal movement-related functions.
Mechanisms of symptom production Gifford (1997) outlines pain mechanisms whlch are rele vant to the rehabilitation of movement and which should be identified and specifically dealt with by phYSiotherapists as part of the desire to maximize the individual patient's movement potential. The clinical pattern for each mechanism is also detailed by Butler (2000) and includes the follOWing. •
strong stimulus-response relationshlp (active and passive joint movement/muscle contraction or muscle length testing should be symptomatic). •
•
•
•
•
Central pain mechanisms - due to central sensitization and processing or sampling of input affected by nociceptive barrage. Such mechanisms are affected by descending modulation such as cognition, emo tion and chemical activity (there is a weak stimulus response relationshlp). One example is phantom pain. Mobilization may help to remove the nociceptive barrage, otl1erwise processing needs to be influenced to recondition movement (Shacklock 1999a).
•
Sympathetic and motor mechanisms (efferent/ output) due to prolonged maladaptive muscle activity, sym pathetic outflow, endocrine activity and in1mune responses. All these factors must be suppressed back to normal to allow homeostasis. This will include: 1. mobilization of locally affected tissue to reduce nociceptive activity, mechanical inflammation and immune responses; this may also influence maladaptive muscle activity 2. mobilization of the thoracic spine and ribs to affect sympathetic chain activity (Slater & Wright 1995) 3. recovery of normal ranges and quality of movement through stretcrung and re-education.
intra-articular (inner capsule, surface opposition) periarticular (outer capsule, ligaments, tendons crossing joints) muscular (contractile, non-contractile, supporting elements) neural (intra-, extra-, entrapment, supporting elements) others (bone, bursae, fat pads, fascia, blood vessels).
Movement-related diagnoses and pathology Corrigan and Maitland (1983) identify orthopaedic con ditions whlch are likely to respond best to treatment by mobilization/manipulation including: •
•
•
•
injury / trauma to joints, muscles, nerves and their supporting tissues inflammation associated with trauma or mechanical disorders degenerative changes associated with ageing, wear and tear or disease disease whlch is inactive and results in pain and restriction of the neuromusculoskeletal system.
-
•
Movement-related structures
•
Peripheral neurogenic pain due to nerve injury with accompanying allodynia/hyperalgesia/ dysaesthe sia as well as neurological signs (symptoms repro ducible with neurodynamic testing) (Greening & Lynn 1998, Butler 2000).
Identifying movement-related disorders from the theoretical side of the brick wall Maitland (1 992) identified the types of structures involved as:
Nociception - tissue-specific symptoms which have a
•
including depression and low mood. These mecl1anisms often, but not always, have their origins in musculoskeletal injury and movement impairment. These patients need good cognitive-behavioural management (Harding 1997) but one must remember that they still probably have a movement impairment(s) whlch has developed from maladaptive mechanisms and whlch, in skilled hands, needs to be mobilized. This in turn could contribute to the patient regaining trust in movement and therefore having an effect on the way the symptoms are processed.
Affective mechanisms
-
251
252
MAITLAND'S PERIPHERAL MANIPULATION
[
Temporomandibular joint (Chapter 17)
•
Carpal tunnel syndrome
•
Intracapsular disorder (reciprocal click, closed lock)
•
Osteoarthritis/rheumatoid arthritis
•
Trauma (e.g. whiplash)
•
Dental malocclusion
•
Work-related upper limb disorders
•
Cervical predisposition
•
Sudeck's atrophy
•
Generalized hypermobility
•
Inferior radioulnar dysfunction
•
Growth/developmental disorders
•
Dequervain's tenosynovitis
(interphalangeal/ metacarpophalangeal)
•
Myofascial pain
•
Overuse (e.g. at the dentist)
Shoulder complex
Hip •
(Chapter 11)
•
Subacromial impingement
•
Shoulder instability
•
Frozen shoulder/adhesive capsulitis
•
Groin strain
•
Juvenile disease (Perthes/slipped epiphysis)
•
Bursitis (psoas/subtrochanteric)
•
Fractured neck of humerus/greater tuberosity
•
Osteoarthritis (glenohumeral/acromioclavicular)
•
Osteoarthritis (tibiofemoral/patellofemoral) Ligament injury (medial/cruciate)
Knee complex
(Chapter 15)
•
Subluxed acromioclavicular joint
•
•
Scapulothoracic dysfunction
•
Internal derangement (meniscal/loose bodies)
•
Sternoclavicular joint pain and stiffness
•
Chondromalacia patellae
Elbow complex
(Chapter 12)
•
Lateral epicondylalgia (tennis elbow)
•
Golfer's elbow
•
Fractures of the head of radius/ olecranon
•
Olecranon bursitis
Wrist and hand complex
(Chapter 13)
•
Osgood-Schlatter's disease
•
Femoral/tibial/intra-articular fractures
Foot and ankle •
(Chapter 16)
Fractures (malleolar/calcaneus phalanges)
•
Ligament sprains
•
Osteoarthritis (talocrural, subtalar , st MTP)
•
Colles/Smith's fractures
•
Achilles tendonitis
•
Scaphoid/metacarpal fractures
•
Plantar fasciitis
•
Sprained wrist
•
Metatarsalgia
•
Crush injuries/laceration/burns
•
Biomechanical dysfunction
•
symptoms which correspond to neuromusculoskeletal struc tures (know your surface anatomy and patterns of referred pain). 'The aching is in my shoulder and I feel a band of pain around my upper arm when I try to comb my hair.' (Fig. 10.1) .
•
Behaviour of symptoms (including tl1e degree o f sever ity and irritability relevant to the stage of the disor der and their relationship to ilie amount and type of activity provoking ilie symptoms - do features fit?) symptoms whid1 are responsible for or are comparable wiili movement impairment and activity limitations diurnally. 'My ankle is stiff when I first get up in ilie morning; it hurts to walk down stairs. I limp when going up ilie slope into my office at work.'
•
Present and past history symptoms and functional limitations related to injury, compromise or benign
Clinical syndromes Each region of the upper limb and the lower limb has clinical syndromes which present as typical patterns and recognizable syndromes, and which respond in often predictable ways to mobilization treatment tech niques as outlined in Box 10.2.
Identifying movement-related disorders from the clinical side of the brick wall (history, symptoms, signs) Subjective examination •
(Chapter 14)
Osteoarthritis
The patient's main complaint symptoms (pain, stiff ness, weakness, etc.) an.d functional limitations with a strong relationship to movements, activities or positions. 'I cannot kneel down because my knee hurts when I try to get up again.' -
Site/locality of symptoms (body chart)
-
-
Peripheral neuromusculoskeletal disorders
Figure 10.1
Recognizable
shoulder joint symptoms.
Ache 'Deep in' Intermittent
® Comes on when G)tt
disease of the neuromusculoskeletal system. 'My tennis elbow originally started after I played in a long badminton match against my wife. I think I gripped the racket too hard in the effort to beat her. She still won. Now I get episodes of it when I sit and work on the computer for long periods.' •
Special questions to reveal whether associated symptoms such as dizziness, neurological or other vascular symptoms (e.g. claudication) have any relationship to movement or functional activity. 'The numbness in my little finger is there all the time, the only other time I feel it more is when it wakes me at night. I think I must lie on my arm or something.'
•
detectable changes in quality and/ or quantity of functional, active move ment which correspond to or are comparable with the patient's symptoms (range/symptom response/ quality of movement). 'When I try to straighten my knee I can tell that it does not go back fully com pared with the other knee and it hurts under my knee cap.'
•
Passive movements (movement diagram) passive test
-
Physical examination (movement impairments) •
over to one side and as I can see when you straighten it up this is very painful.'
alignment faults, protective deform ities, anomalies, wasting and asymmetry, all of which may correspond to the patient's symptoms (comparable signs). 'You are holding your wrist
Observation
-
Functional, active movement
-
-
ing of joint accessory movements and physiological movements, neurodynarnics and muscle lengths where the 'joint' signs/neural provocative signs or length changes alter correspondingly with move ment. Where there is a strong relationship between pain, resistance, spasm and movement, passive movements reproduce the patient's symptoms. 'When I bend your big toe like this (passive flexion of the first metatarsophalangeal joint) does the pain increase the more I bend it?'
253
254
MAITLAND'S PERI PHERAL MANIPULATION
•
detectable, objective signs in the neuro musculoskeletal structures which fit in with the nature of the disorder, from the cardinal signs of acute inflammation after injury to the bony and soft tissue thickening around an arthritic joint. 'When I palpate your ankle I can feel that the ligament is a bit swollen and thickened at the spot where you say it hurts.'
Palpation
-
Response to treatment by mobilization/ manipulation Pain emanating from the neuromusculoskeletal struc tures which are being moved in a skilled appropriate manner should subside and allow greater active movement without pain, if the pain is in fact related to movement (groups 1 and 3a, Chapter 7) (Wright & Sluka 2001). 'I see that you can now open your mouth further before it hurts since I performed that gentle treatment on your jaw' ( grade I pain -free small ampli
tude transverse movement medially on the TMJ). Increased resistance to movement due to stiffness of the structures of the movement system will decrease if these structures are stretched in a controlled and appropriate way (groups 2, 3b, Chapter 8) (Hunter 1994). 'I see that you can now lift your arm further since I stretched your shoulder ' (peak of the quadrant, Chapter 11). Protective involuntary muscle spasm due to impair ment of the movement system structures will reduce with appropriate passive movement techniques if this spasm is related to impairment of movement (Chapter 8). 'You do not seem to be holding your knee so bent now after I worked into the bite of pain which seemed to release some of that protective spasm.'
Non-movement-related disorders The manipulative physiotherapist, especially a first contact practitioner, should always be on the lookout for non-neuromusculoskeletal disorders which mimic neuromusculoskeletal disorders. Certain symptoms, signs and patterns of history should ring alarm bells in the mind of the clinician. For example, severe spontan eous hip pain in young obese juvenile males (slipped epiphysis), gripping left shoulder and arm pain with exertion or when under stress (cardiac), pulsating/ cramp in the legs after walking or sporting activities (claudication), to name but a few. Symptoms which do not appear to bear any resem blance to movement, activity or functional positions are less likely to respond to movement-related therapies. The manipulative physiotherapist should have a good working knowledge and experience of other body systems in order to recognize their mechanisms of
symptom production and how disorders of the car diovascular, respiratory, gastrointestinal, endocrine, genitourinary and immune systems can mimic neuro musculoskeletal symptoms. (Physiotherapists often fol Iow a specialized path of professional development too quickly in their careers and therefore miss out on this essential knowledge and experience of health-care pro vision.) Such relevant profiles will be discussed in more detail later in this chapter in relation to the role of the manipulative physiotherapist in differential diagnosis.
NATURAL HISTORIES (INSIDIOUS, TRAUMATIC) Introduction Most common neuromusculoskeletal disorders run predictable or predictably unpredictable courses. The body has an inherent capacity to heal over a fairly pre dictable timeframe (Hunter 1994). Butler (2000), how ever, has highlighted the fact that pain often runs a different natural history from tissue healing and that this should be considered when explaining and pre dicting outcomes. The main factors which influence an individual's recovery from a typical neuromusculoskeletal dis order are the myriad contributing factors or barriers to recovery (Chapter 8) such as 'misuse', 'overuse', or some structural, functional, psychosocial or systemic disease reasons, many of which occur together and interact to affect the way that the disorder progresses (or does not progress) throughout its natural history. Many typical neuromusculoskeletal disorders also respond in a fairly predictable way to mobilization and manipulation and with experience these rates and stages of progression can be recognized. Early intervention after injury or onset of spontan eous episodes can help to modify the disorder's natural history. As discussed in Chapter 8, mobilization/ manipulation techniques are only one part of the manipulative physiotherapy process which can con tribute to: • • •
the quality of repair and healing the facilitation of homeostasis the patient's whole experience (including knowledge, emotions and sampling for future reference).
Grouping the natural history of the disorder can be valuable in the following ways: •
It helps the physiotherapist to develop skills in prognosis in terms of treatment expectations, likelihood of recurrences and the development of preventative measures.
Peripheral neuromusculoskeletal disorders
•
It helps to develop skills in seeking the reason for a particular disorder's onset. To be able to ask the correct questions to extract this most important part of the history requires knowledge about the potential factors involved in the onset of the different groups.
The history of the disorder can be characterized by the insidious or traumatic nature of its onset.
Insidious onset Understanding the cause of the insidious onset is essen tial to understanding the patient's presenting signs and symptoms and assessing the prognosis for recovery (Fig. 10.2). Some patients have a familial or genetic pre disposition to develop certain disorders when other fac tors are present. Other disorders develop as a result of predisposing activities. Then there are those who have had an unrecognized trivial incident. In all three situ ations the patient is often unaware of the reason for the onset of symptoms. Skilled questioning is essential to establish the relationship of any predisposing factor to the presenting symptoms.
Familial/genetic predisposition An example of this is those patients who might loosely be called 'jointy people', often referred to as having 'acute joint awareness' or 'genetic sensitivity'. They have symptoms in different joint areas from time to time. The symptoms may 'come-and-go' for no obvi ous reason and they rarely seek treatment unless the symptoms persist or restrict their normal activities. Tracing familial components to the disorder often reveals somewhat similar symptoms in another sibling or in one of the parents. The actual onset of symptoms for patients in this cat egory is never straightforward, yet it does have a general pattern. The current symptoms for which they seek treatment do have a reasonably standard onset. The onset is either (a) that the patient has noticed developing symptoms during and after performing an activity
Figure 10.2
Causes of insidious onset.
with which there would normally be no difficulties, or (b) that aching has been noticed in different joint areas for short periods (2 or 3 days) over the preceding few months (2-3 months or more). This commonly begins when the patient is in the early thirties. The patient knows of no reason why they should have developed. Delving into the background of the disorder's earlier history might have a dialogue similar to the following: ET There has to be some reason why the symptoms should have begun and somehow we should be able to 'make the features fit'. Q 'Can you recall when you first had any symp toms, however mild they may have been?' ET If he seems to be taking an inordinate length of time trying to answer, I'll help him by giving two extremes for him to choose from. Q 'Are you thinking in terms of weeks or years?' A 'The recent trouble has been about 3 months, but 1 was trying to think about the months, and even 2 or 3 years you mentioned because as a child 1 was supposed to have had what they called 'growing pains'.' Q 'Well, if we say your present problem started 4 months ago, are you saying that 5, 6 or 7 months ago you were totally symptom free?' A 'No, not totally free. 1 have had occasional aware ness of an ache in my shoulder or hip, even my elbow and knee, for a day or two at a time, but other wise 1 would say 1 have been without symptoms.' Q 'Can you relate those 1 or 2 days of aching to anything?' A 'No, 1 don't think so.' Q 'Could you have been doing anything different at the time?' A 'No, not that 1 can think of.' Q 'Might you have been unwell or overtired?' A 'I could have been overtired. 1 am under pressure at work from time to time.' Q 'And have these been at times when you had symptoms?' A 'They could well have been.' ET This isn't getting me far, but there is one useful avenue 1 could follow up. Q 'Do you do different things at the weekends from what you do during the week at work?' A 'Yes, quite different. I work in the garden most weekends.' Q 'And does that cause any symptoms?' A 'Well it does, but 1 feel that more on Mondays.' Q 'And what is it like on Tuesdays?' A 'Much better, nearly all gone - certainly gone by Tuesday evening.'
255
256
MAITLAND'S PERIPHERAL MANIPULATION
L 'And is that pain much the same as your present problem?' A 'Yes, much the same but it is more general.' ET I wonder if he has ever had an episode of pain similar to this episode. I feel I have a responsibility to exclude this possibility anyway. If he has had an acute episode it may indicate that he could have a more 'active' disorder. Q 'Have you at any time had more severe symp toms, perhaps even temporarily preventing you from doing certain activities; may have lasted a few weeks?' A 'No, not at all.' ET Well that clarifies those predisposing possibilities. Q 'Have any other members of your family, parents, brothers, sisters had any aches and pains like yours?' A 'Yes, my sister and my mother have had problems. My mother's is mainly in her hip but my sister has had much the same as me.' ET That's a big help to me. It seems that (a) there may be some familial or genetic predisposition, (b) his body can't, at the moment, take exercise like gardening without complaint, and (c) if the growing pains are part of the history, his disorder, in one form or another, is very longstanding. It influences my treatment goal - I would hope that I can settle his present symptoms to their previous state - I might also be prepared to treat the other symptoms. I know that he can't be made symptom or sign free but I know I have three prophylactic measures that may improve his future: 1. Gravity-assisted, large-range, loose swinging type movements. 2. If his body can accept the gravity-assisted exercises I can add isometric and then isotonic exercises. 3. Perhaps the most useful thing would be to teach another member of the family to passive mobilize gently the symptomatic areas using large-range symptomless movements. This should be explained to him in full so that his expectations are put into their proper perspective. He can then know and understand that his care is an ongoing one for which he can return for treat ment if his own home treatment is not sufficiently successful. Q
Predisposition through use As a distinctly separate group, there are the people who have predisposing activities as the background to the onset of their symptoms. This is a complex section
with many subdivisions and much overlapping. The predisposing components are widely varied and often relate to the office worker who, at tl1e weekend, per forms different and physical activities. It also applies to people playing sport, subjecting themselves to ever increasing levels of their particular activity. This latter group also includes middle-aged people who decide that they should endeavour to become fit by doing a regimen of exercises for the first time. They develop symptoms when the exercising exceeds that to which their bodies can adapt. All of the subdivisions of predisposition through use relate to two factors. The first is the type and vigour of an activity being performed and the second is the state of the structures being used and their abil ity to accept the use. It is this second factor that is fre quently not adequately taken into account. The human body has an enormous capacity to adapt to demands, and if the demands are gradually and progressively increased within the limits of pain, ligaments can thicken and strengthen, muscles can develop and support more strongly, and even bony growths can develop to support around joints and in ligaments/ tendons. The different types of predisposition through use that can exist are: 1. 2. 3. 4.
New use. Misuse. Overuse. Abuse. 5. Disuse. 'New-use' is self-explanatory. It relates to a person per forming some activity that he has either not performed before, or has not performed for a long time. The result from performing this new activity (a) for too long, (b) too strenuously, or (c) beyond the capacities of the structures involved at their present state of health, will be pain. If each part (a-c above) in the 'new use' activity is unfavourable, the resultant pain will be great, and the recovery time will be long. The historical questions that need to be asked are: 'How heavy a job was it?' 'How long did you do it for?' 'Have you ever done this before?' (A 'No.') 'Did you stop because the job was completed, or because you couldn't physically go on with it any longer?' 'Did you feel any discomfort or pain while you were doing it or was it after you stopped?' 'Have you had any symptoms (grades of pain or weakness) in this area before?' (This is seeking
Peripheral neuromusculoskeletal disorders
predisposition by virtue of lowered capacities of the struchlres involved.)
The information needed for the history is:
Q
The answers to these questions, and their relation to the severity and duration of the presenting disorder, provide the information needed to make a treatment success prognosis. 'Misuse' relates to having to carry out a function that was awkward or an activity that was performed in an unnecessarily silly manner, either of which, if per formed without constraints, would have been done
'Can you demonstrate for me now the action that causes the pain?' 'How long have you been doing it in this particular manner?' 'For how long do you do it at a time?' 'How often do you do it?' 'Did the pain first start as a sudden onset at one particular moment?'
If it had a sudden onset, it could be classed as 'abuse'
differently. In other words, the muscles, ligaments and
(see below) superimposed on 'overuse', or as 'overuse'
joints have been stressed by the awkwardness of the
reaching the breaking points of the structures beyond
function.
the body's ability to adapt to the demands.
Under these circumstances, as with 'new use', the
If the symptoms develop gradually over a period of
awkwardness and the severity of the symptoms need
1-3 weeks of daily
to be related to the severity of the activity, and any pre
not quite been reached, but the warning is there, and it
disposition would be determined and interrelated.
soon will be reached if the same demand is continued.
repetition, then breaking point has
There is one objective examination test that may need
The gradual onset of symptoms is an 'overuse' situ
to be carried out and that is to ask the patient to simu
ation. It can normally be remedied if the activity is
late the function that caused the symptoms while the
stopped prior to the onset of pain. When pain is the
therapist tests the structures in this function.
limiting factor, treatment by passive movement should
'Overuse' is another self-explanatory term. All of the structures that together form the human body have a breaking point. Many of these structures in most people can have their breaking point raised by train ing. However, there is a limit to how far the body can
be performed intermittently, slowly, smoothly and gen tly through as full a
range as possible such that no pain
is reproduced. Once the pain is relieved, controlled exercises combined with a gradual increase of the over use activity can be implemented. Fry
(1986) provides
adapt, and this varies enormously from one individual
an excellent paper on this overuse in which he says:
to another. For example, a man whose talent and train
Overuse syndrome in musicians, a common disorder, is characterized by pain and loss of function in muscles and joint ligaments of the upper limb. In wind players the same process can affect the muscles forming the embouchure, the soft palate and the muscles of the throat. Individuals vary in susceptibility, so the threshold of overuse cannot be known in advance ... the condition is typically
ing enabled him to be a successful 'weight-lifter ' and 'bottom-man' in a balancing and acrobatic team had a pain-free life until he was
85 years of age when he
developed shoulder pain from manually clipping edges of a lawn while on his hands and knees. The point of interest was that he was forhmate enough to have a body which, during his active life, could adapt to the demands he placed upon it. His vertebrae had bony bridges between them and his tenomuscular and musculotendinous jlmctions were reinforced by bony components. Yet he had not had a pain throughout his life until the short-lived shoulder pain. The human body is extraordinary beyond our comprehension, a point never to be forgotten. When a patient presents for treatment with symp toms that can be put down to a vigorous 'overuse' situ ation, the problems are only just beginning. People playing high-grade competitive sports, especially if the sport consists of long durations of the activity at a time, are prone to develop symptoms. This is because they exceed the limit of the body's adaptation to the demand. This does not mean that they will not respond to treatment and appropriate retraining, but the mixture of treatment and retraining requires a very sensible understanding attitude by the patient.
brought on by an increase in the duration and intensity
of practice or playing ...
'Abuse', as with the other terms, is self-explanatory. It relates to a person who physically abuses his body (or parts of it) beyond reasonable limits. If the abuse is considered in the 'spontaneous onset' group the his tory will not contain a once-only abuse resulting in sudden injury or pain, but rather it will consist of repetitive abuse until pain is felt. The person usually continues the abuse until he becomes disabled . These abusive actions are those that, no matter how fit or well trained the person performing them is, he would still be classified as abUSing his body. The history is straightforward, but it is necessary to know:
1. How long the abusive activity has been going on for.
257
258
MAITLAND'S PERIPHERAL MANIPULATION
2. At what stage it became symptomatic. 3. How long it was continued before he decided that
1. Poorly shaped femoral condyles that predispose to recurrent subluxation of the patella. The joint is
he could not carry on any longer.
4. Were there any 'predisposing factors' that may indicate that the degree of abuse:
disadvantaged structurally (genetically).
2. The 'overuse' and 'abuse' situations. Here, repetitive stressful asymptomatic use of a joint, such as to the
(a) caused the pain sooner than would have
knee and ankle in people who compete in events such
been the case otherwise; or (b) is the severity of
as the springboard/vaulting-horse, disadvantages
the disability greater than would otherwise have
the joints for their future.
been the case? 5.
Has the abuse effect been further worsened by its
3. A joint sprain that ruptures a ligament, such as the
causing an active inflammatory response?
medial ligament of the knee, renders the joint disadvantaged.
In defence of the person who does perform abusive type activities, it must be realized that he must be get
(2) and (3) have been referred to in the sections on 'new
ting an enormous gratification from whatever it is he is
use', 'misuse', 'overuse' and 'abuse', but they were not
doing. It is not necessarily right to stop him doing it
characterized as being 'disadvantaged'. However, it is
because of the long-term ill-effect it may have. To stop
the first one - the genetically structured joint described
him may have a longer term ill-effect.
above - that is the 'disadvantaged' joint which may be
'Disuse' merely puts the body at a disadvantage at a
the underlying basis for a disorder.
time when the person may be in a position where an active demand is put on him. If the same demand is put on a person who is normally active, symptoms will not develop. In terms of history taking, the require ment is to determine how unfit, in terms of use (dis use), is the part of the body on which the demand is to be put. That is the first approach to the history. The second is to determine the 'disuse' in terms of laziness compared with genetic inability, and to previous injury / disease resulting in forced disuse. The impor tance of this questioning lies in the information it gives about the prognosis of rehabilitation and preventing recurrence of symptoms. The longer the body is subjected to any of the above predispositions (new use, misuse, overuse, abuse, dis
Trivial incident It is common for patients to present with the history of an incident that is trivial. One example of the trivial incident group is when a person leans over the back of the front seat of a car to lift up a parcel from the back seat. This action causes a sharp pain in the shoulder which lasts no more than a second. This incident is for gotten, but the shoulder developed a moderate ache some weeks later. Such a trivial incident produces last ing symptoms; the therapist should look for a predis posing factor.
Traumatic onset
use), the greater is the likelihood that injury will occur.
Sprain and direct injury are included under this main
For example, in relation to the underlying overuse:
heading, and each has its differences.
(a) the greater the vigour and frequency of the overuse,
As with the 'insidious onset' disorders, 'typical' and
and (b) the longer the duration of the overuse (i) per
'atypical' also apply. For example, the common type of
day and (ii) per lifetime, the less the structures being
sprained ankle or the torn medial meniscus of the knee
overused can tolerate, and therefore the less the injur
are typical in their presentation of history symptoms
ing force needs to be to cause disability. Furthermore,
and signs. In contrast, a pedestrian or. cyclist being
when one predisposition through use is superimposed
knocked over by a motor vehicle will not be typical or
on another, the effects are compounded.
regular in the presentation of symptoms and signs. Though they may have parts of their symptoms and signs that resemble regular patterns, overall they will
Disadvantaged joints To repeat, the word joint here is used loosely to cover widely all inert components associated with the mov ing joint. A disadvantaged joint has some structural anomaly for change which renders it prone to cause symptoms if it is subjected tq a stress. The same stress
be very irregular in their presentation (Fig.
pected unguarded movement forced on the part which becomes injured. A sprained ankle is the one that most readily comes to mind. The history is important.
Q
to a 'normal' joint with a normal configuration would not cause symptoms. Examples demonstrate three varieties of 'disadvantage joints'.
10.3).
Sprain indicates that the person has had an unex
'What actually happened? How did you 'go over' on your ankle?'
A
'I don't really know. I was playing football at the time - I had just got hold of the ball and twisted
Peripheral neuromusculoskeletal disorders
Q
of readers: 'Would you have thought of that?' I wouldn't (and didn't).
ET The examiner may have found this out by asking him where his bruising was, to which he would have probably indicated the common areas for a sprained ankle, plus a few more, plus two football boot sprig holes on the lateral-proximal dorsum of the foot. So it becomes obvious that it is necessary to determine in just what directions and how the sprain occurred. This applies to any 'sprain' of any moving part (muscle, ligament, tendon, capsule, nerve). It is then often nec Figure 10.3
Presentation of trauma.
essary to ask the patient to demonstrate the spraining movement as well as other movements that reproduce
to get away from the opposition and just went over on my ankle.'
Q
'Did you go over on the ankle on the inside of the direction to which you twisted?'
(Don't go on to say 'or was it the foot on the outside of the direction you twisted?' To understand the reasoning for stating this, just read out each of the ways of asking the question to yourself a few times and assess which is the easiest to formulate the answer for.)
YOU are concerned . . . is your ... main
problem?' His answer would have been something like 'pain in my ankle when walking on uneven ground or when running.'
Q
In fact the above story is of a real patient: one who had not responded to other physiotherapy which had been applied in a manner to suit the common variety of sprained ankle. It is necessary to be open-minded and alert to what might be atypical. When he described his injury, and was then asked to demonstrate how it happened, he stood up, asked that the right foot be held firmly on the ground, then he twisted his whole body towards the left, and with his left foot facing in almost the opposite direction to his fixed right foot he flexed his body forwards (twisted of course) over his
ET The examiner's question would have been 'What, as far as
the symptoms.
'Show me where you feel this.'
(which he proceeds to
flexed left knee and hip, then tried to pull his right foot off the fixed position on the floor. 'His' pain was repro duced by the movement. Treating this with gentle oscillatory stretches in this position, and gradually increasing the strength of the oscillatory stretches as pain decreased, was the primary treatment which relieved him of his disability.
do; then . . . ) Q
'What caused it?'
A
'I sprained my ankle at footy.'
Make features fit Make features fit - this statement of 'making-features
Two thoughts might come to mind: (a) that spraining
fit' cannot be overemphasized. Just suppose that a
an ankle at football might not be the same as spraining
patient had sprained an ankle a year ago and it had
an ankle when, say, stepping down a gutter; and
still not recovered (say there was still a
(b) the areas of pain he has indicated would probably,
disability)
under these circumstances, be different from the more
sounded to have been reasonably senSibly applied,
common sprained ankle. As the pain isn't totally typ
then the 'features don't fit'. So, why?
ical, detailed questioning is needed. He stated that it
about this sprained ankle?
despite
continued
40% degree of
treatment
which
What is different
One should not just give up
was his ankle on the outside of the direction to which
and say 'you'll have to live with it' without delving
he twisted which he 'went-over' on.
more deeply into the story, previous history, otller associable illnesses, pattern of symptoms, immediate
Q
'Did you fall?'
responses to physical treatment, what the patient's
A
'No, I just couldn't keep going.'
body (in this example, his foot) can tell him about what
ET
Never assume anything.
it likes and dislikes having done to it - there is almost
Q
'Why couldn't you keep going?'
no end to the probing to be done to make sense out of
A
'The other bloke slammed his foot on top of mine
the story - why isn't it getting better? He can't just be
and pinned it to the ground.'
left like this, what can we do?
259
260
MAITLAND'S PERIPHERAL MANI PULATION
As well as probing questioning there is the prob ing physical examination - using combinations of movements, using functional resisted movements at speed, movements with strong compression. There must be something to find, by questioning or examin ing, to make features fit before deciding that it is a hysterical disorder, and there aren't too many of those. Unguarded movements, unprotected movements, and flicking movements beyond muscular protection are among the most difficult disorders to restore to normal. They create a degree of damage that is far greater than one would expect. It is important to remember this when endeavouring to 'make features fit' in relation to treatment response and examination findings. Direct injury is quite different from sprain though sprains may be part of the total injury. Knowing details of the accident provides considerable useful information which may guide treatment, so this forms an important part of the history. Any previous history in the areas injured by the accident often help to 'make the features fit' more exactly. But really, the most important part of the examination (and subsequent direction of treatment) lies in the answers to the questions: Q Q
'At this stage - what is your main problem?' 'What is it that you can't do at this stage?'
An example of this is a young man who had had his right arm from his hand to his shoulder badly squashed in a car accident. Question: What can't he do at this stage (some 9 months after the injury)? He couldn't lift a motor car tyre off the floor. So what? He was a motor mechanic and if he could only lift a car tyre off the floor he could return to work despite his other arm injuries and disabilities. And so it is obvious where the aim of treatment would lie at that stage.
STRUCT URES AT FAULT The manipulative physiotherapist should be able to recognize clinical features of the individual base com ponents of the movement system within what are quite often muiticomponent neuromusculoskeletal dis orders. What follows is a broad profile of each of these components.
Articul ar Uoint) : intra-articular I periarticular •
•
•
•
•
•
•
Typical descriptors - aching, stiffness, sore/tender over injured ligaments. Recognizable areas - 'in' the joint, over ligaments, bands of aching/pain across the joint/around the limb. Functional loss of range, pain/aching with compression of the joint. Onset of problems which corresponds to overuse/misuse/ abuse/new use/ disuse of the joint, injury or compromise involving the joint, joint disease processes such as rheumatoid arthritis. Recognizable patterns of restriction (e.g. capsular pattern of the shoulder, arc of shouJ.der pain). Joint signs correspond with passive physiological and accessory movement. Pain and resistance are strongly related with passive movement.
Periarticu/ar (Fig. 1 0.4) •
Behaviour of symptoms with movement, i.e. symp toms increase proportionally with the amount of stretch applied to the periarticular tissue, whether acute or chronic. Symptoms increase at the end of
in pain-free position
Figure 10.4
Differentiation between intra-articular and periarticular disorders. EOR, end of range.
Peripheral neuromusculoskeleta l disorders
261
] range or end of the available range. Often this stretch corresponds to the injuring movement. •
Behaviour of symptoms with rest, i.e. periarticular structures will not be painful or as painful if they are not in a position of stretch or squash or if they are neither inflamed nor severely damaged.
Intra-articular (Fig. 1 0.4) •
•
Behaviour of symptoms with movement, i.e. symp toms tend to occur through a large section of the range of movement being tested (through-range symptoms). Symptoms will often increase with activities that involve compression of the joint sur faces such as lying on the hip or shoulder. In chronic disorders where pain is not severe, through-range or end-of-range movements on their own may not be painful but they certainly will be if the joint is moved with the surfaces firmly compressed together. Behaviour of symptoms with rest, i.e. the joint will be painful if it is being compressed at rest. Very painful intra-articular disorders will be painful at rest even when the joint is positioned in an unstressed, well supported, neutral position.
intra-articular symptoms will be approximately unchanged or they will be worse. Q 'How does it feel when you first get out of bed?' ET Both may feel stiffer than at other times but the length of time they remain stiff is different. A 'It feels a bit stiff and painful.' Q 'How long does that stiffness and pain last?' OR Q Al ET A2 ET Q A ET
Many joint conditions will have components of both intra- and periarticular disorder. An osteoarthritic hip, say, when it is in an active phase will have a through range pain which can be increased when the surfaces are gently opposed but will also have an increase in end-of-range pain when being stretched.
Differentiation between intra-articular and periarticular disorders with compression sustained Another consideration related to resting pain is that a patient with a chronic intra-articular disorder may have discomfort when lying on the painful joint. On examination of this joint, it should be possible to repro duce these symptoms by compressing the adjacent articular surfaces together and sustaining the strong compression. Periarticular disorders will not be pain ful with this test. In the subjective part of the examination, the fol lowing questions are asked: 'How does it feel when you waken in the morning compared with when you go to bed?' ET The word 'it' is used to allow for spontaneous responses about anything the patient may feel at that time, rather than to restrict his thinking by asking 'How does the pain feel etc.'. In general, periarticular symptoms will be improved, whereas Q
'How long does it take for that to subside to its usual level?' 'Only a short time - it's all right by the time I've had my shower. ' This is not an intra-articular or an inflammatory disorder. 'It gradually settles down.' That is not enough depth of information. 'What length of time are you thinking of, (ET Help him) 10 minutes or more than half an hour?' 'I suppose it's more like an hour or so.' This is likely to be intra-articular and inflamma tory. In fact it is not uncommon for such a disorder to make it impossible for a patient to be able to stay in bed all night. He may well have to get out of bed, at least once, for half an hour or more before the increased symptoms subside enough to allow him to go back to bed. As a side-issue to this, but worth stating here, he should be taught how to do pendular movements which he should do when he is forced to get out of bed. These pendu lar movements should be small range, oscillatory painless movements produced by other parts of the body rather than the prime movers of the joint(s) affected. These movements, if well per formed, will reduce the pain and enable him to go back to bed much more quickly.
Myofascial (muscle) •
•
• •
•
•
Complaints of weakness and reduced strength in the muscle (detailed questioning should reveal whether this is due to disuse atrophy, pain inhibition or neurological conduction loss to the muscle). Soreness, tenderness of the muscle when stretched or squeezed. Aching distally into recognized referred pain areas. Pain reproduced in the muscle when it is stretched (NB: further sensitizing additions of neural tissue will need to be performed to help differentiate the stretch feeling further). History of muscle tear, contusion, overstrain, overuse injury. Quality of movement affected more than quantity.
262
MAITLAND'S PERIPHERAL MANIPULATION
[ • •
•
•
•
Wasting/ fasciculation evident. Alignment faults and dynamic stability faults observable with functional movement. Pain consistent between active movement and isometric testing but not with passive movement. Poorly correlated active and passive ranges (active and passive insufficiency). More elastic end-feel to muscle length testing compared with articular tissue.
Neural (pathoneurodynamics) •
• •
•
•
•
•
•
•
Both mechanical and physiological mechanisms which correspond to each other. Burning lines of pain along nerve courses. Accompanying hyperalgesia, allodynia, dysaesthesia, paraesthesia, anaesthesia. Symptoms accompany mechanical provocation of neural tissue (lengthening, sustained compression). A history corresponding to either obvious nerve injury (compression, laceration, stretch, ischaemia, toxic infiltration, predisposing disease) or slowly developing compromise (keyboard workers, musicians, etc.). Impairment of tissues which interface with neural tissue and could influence normal mechanics of neural tissue. Antalgic postures which reduce the mechanical provocation of neural tissue. Passive neural provocation tests and sensitization are positive in terms of reproducing symptoms or being sensitive to movement. Often muscle protection can be felt as the sign which protects the sensitive neural tissue from further provocation (Elvey & Hall 1999).
MEC HANISMS OF SYMPTOM PRO DUCTION (PAIN MECHANISMS) It is not the intention in this text to review pain mech anisms in any great detail as this has been presented in other physiotherapy textbooks (Gifford 1997, Butler 2000). An understanding of such mechanisms of symptom production, however, is essential for the manipulative physiotherapist to be able to decide how and when manipulative physiotherapy, and in particu lar mobilization/manipulation treatment techniques, should be used in each individual case of neuromuscu loskeletal disorder. What is clear according to Butler (2000) is that all the mechanisms of nociception and peripheral neurogenic pain (input), central sensitization and
psychological/brain sampling (processing) and auto nomic, endocrine, immune, motor and pain control mechanisms (output and homeostasis) interact with each other all the time. Nociception is pain roughly coming from where it is felt or at least where tissue damage and inflamma tion are stimulating nociceptors to transmit impulses that produce the perception of pain in the brain. Referred pain can be a consequence of nociception, whereby - through convergence theory (Watson 1986) for example - pain can be felt in a site removed from the tissue-based mechanisms. Nociceptors can be gen erated by mechanical, chemical or ischaemic stimuli. Greening and Lynn (1998) say of peripheral neuro genic mechanisms that 'studies demonstrate that pain and changed somatosensory thresholds . . . may occur following relatively minor axonal damage . . . ' Once again pain is felt to be coming from the injured nerve; however, dysaesthesia, hyperalgeSia and allodynia are likely to accompany the pain both locally and at other sites and tissues along the nerve course. Central sensitization or dorsal horn cell sensitiza tion and multidimensional processing of nociceptive and peripheral neurogenic input in the central nervous system takes place in all pain states. Central pain tends to persist in chronic pain states. The degree and context of the input, and the conse quent processing of this input, will influence the nature of the output (autonomic, motor, behavioural, endocrine, immune). Gifford (1997) considers this out put to be adaptive in order to assist in the best possible recovery (rest, protect the part, rationalize the pain, staged recovery of normal activity, etc.) or maladaptive which will serve no real purpose in terms of survival and recovery (overprotection, fear avoidance, misin terpreting the pain experience, conflicting advice from peers or medical professionals, enhanced and ampli fied pain experience, etc.). Table 10.1 summarizes pain mechanisms in respect of expected responses to movement. The role of the manipulative physiotherapist in this process can be crucial to recovery and to future responses to any pain experience a patient may have. One key clinical feature of these pain mechanisms which is vital to the correct selection of mobilization/ manipulation treatment technique is the ability of the clinician to recognize primary and secondary
hyperalgesia: •
Primary hyperalgesia is a key feature of nociception and pain emanating from the site of tissue damage and inflammation and the factor which can be most readily influenced by mobilization treatment techniques.
Ta b l e 1 0. 1
S u m m a ry o f m ec h a n i s m s a n d move m e n t responses
Nociception
Peripheral neurogenic pain
Central pain
Mechanical
Nerve injury (mechanically
Centra I sensitization
(inflammatory
enhanced neurogenic
ischaemic)
inflammation): •
M echanical: •
Strong relationship between pain and
•
Stress state related responses
Strong relationship between
Pain response related to
(fight or flight):
unhel pful thoughts and
•
Heightened pain response to
•
Disproportionate true +ve
emotions
pain and nerve tension!
Allodynia:
sliding (mechanosensitive)
•
Weaker stimulus-response
False +ve or enhanced
movem ent
Weak relationship
(maladaptive) tissue
tissue-based responses when
response to movement
pain states are sympathetically
mechanical stress
and mechanical stress
neurogenic inflammation
•
P rimary hyperalgesia
causes secondary
responses to movement
•
True +ve tissue
hypera Igesia
and mechanical stress
•
•
between pain and
relationship where
mechanical stress
Cognitive emotional:
Secondary hyperalgesia
mechanical forces
•
Autonomic sympathetic output
•
movement or
response to
Affective mechanisms
False +ve tissue-based
maintained •
Development of central sensitization
Weaker relationship between secondary hyperalgesia and mechanical stresses
Ischaemic: •
Strong relationship
(proportionally) •
to mechanical stresses
between sustained mechanical forces and pain
True +ve nerve tissue response
•
False +ve tissue response to mechanical stress for secondary hyperalgesia
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264
MAITLAND'S PERIPHERAL MANI PULATION
•
Secondary hyperalgesia is an accompanying feature to nociception in areas around the tissue damage and along the course of injured nerves, but becomes more a feature in protracted central sensitization mechanisms and maladaptive output mechanisms such as sympathetically maintained pain, unhelpful thoughts and fear avoidance of movement.
Box 10.3 outlines the key features of primary and sec ondary hyperalgesia (i.e. an increased response to a stimu lus which is normally painful). This should help the manipulative therapist to select passive movement techniques appropriately, predict the response to treat ment based on the knowledge of the clinical features and interaction of pain mechanisms, and be aware of how injudiciously applied inputs (mobilization tech niques) can enhance central sensitization (nOCiceptive barrage of already sensitive dorsal horn cells) and therefore reinforce maladaptive outputs which become further barriers to recovery.
Primary hyperalgesia 1
Manipulative physiotherapists, therefore, should be prepared to adapt their skills when dealing with pain that has a strong central mechanism to it (the clin ical consequence of which is likely to be, amongst other features, secondary hyperalgesia). Mobilization/ manipulation techniques should be applied with broader desired effects in mind, i.e. manual techniques should be used not just to stretch a joint or reduce tissue-related pain but to: 1. help the patient to regain trust in movement after a painful episode or because the patient thinks that, if it hurts to move, it is doing more harm 2.
maintain movement when passive movement is less painful than active movement, thereby helping to retain an ideal functional movement environment
3. recondition sensitized musculoskeletal tissue with the aim of gradually exposing the patient to (often) long-forgotten, pain-free, normal movement
Secondary hyperalgesia2
Hyperal gesia at the site of injury or inflammatory
Allogeneic chemicals are released into normal tissue,
response
reducing the threshold of firing of nociceptors ; central
A true positive response pain comes from the tissues at the site of the primary hyperalgesia The response is always proportional to the stimulus (the more the structures are stressed the more painful they become ; the more they have been damaged the more the primary hyperalgesia) The severity and irritability of the disorder are proportional to the tissue rea ctivity and the pathological activity The pain response to movement is fairly consistent (pain is reproduced consistently in proportion to the stress o n the hyperalgesic structures) Symptoms i n crease proportionally with activity and reduce with rest
sensitization occurs due to plasticity of dorsal horn receptor cells and higher centre proprioceptors become sensitized to pain (allodynia) ; maladaptive output also occurs (sympathetic outflow, a b normal movement, unhelpful thoughts about pain) False positives - pain is felt in tissues that are not damaged, have not been injured or are still se nsitized long after the injury has healed The relationship between stimulus and response is weak (a movement evokes a much greater response than would be expected in view of the exte nt of damage or time since onset of the episode or inju ry) Severity and irrita bility in such cases ca n be classified as seco nda ry, i.e. the degree of severity and irritability is
Night pain and morning stiffness/soreness may indicate
more in proportion to the secondary hyperalgesia
inflammatory responses
mechanisms than to primary hyperalgesia. This
NSAlDs should help
classification of severity and irritability is related more
Symptoms which increase proportionally to sustained positions or loading may indicate nociception generated by ischaemic mechanisms Palpation findi ngs are consistent with local tissue changes and signs of injury or disadvantage (cardi nal signs of
to the degree of sensitivity experienced by the patient than to the degree of tissue damage/inflammation NSAIDs are less likely to help this neurogenic inflammation Symptoms often increase in proportion to cognitive a nd emotional or social and psychological stress situations
inflammation, trophic, soft tissue and bony cha n ges con
Functional movements exhibit sensitivity and are dispro
sistent with the stage of the disorder's n atural history)
portionately restricted in relation to the extent of, or the
Peripheral neu romusculoskeletal disorders
The movement diagram will correspond to the severity,
time since, the original injury. Functional loss of
irritability, degree of movement impairment and the
movement is inconsistent and variab le from day to day
degree of palpation findings
or week to week
With the movement diagram pain will increase proportional
Rubbing the painful area, heat applied to it or occupying
to movement, and if present together pain and resistance
the mind with something else may temporarily make the
will increase correspondingly with movement
symptoms more acceptable
The history of the present (and past) episodes will fit with
Palpation findings do not often reveal tissue changes in
movement restrictions and the palpation findings. The
proportion to the response encountered. Palpation
onset, progression and stage of the disorder will reflect
findings are constantly changing and labile (some days
the movement impairments found on examination
painful to touch, other days less painful and other days
Tissue-specific treatments will be effective including
painful again). There is little evidence of cardinal signs of
mobilization and manipulation Grade I and II techniques performed in a pain-free manner will work by producing hypoalgesic effects Grade I I I and IV techniques where pain is proportional to the amount of resistance, including the 'bite' of pain, wil l be effective as stretching techniques. As the movement is stretched and the range of movement increases, the pain related to the stiffness will reduce correspondingly
inflammation and soft tissue changes corresponding to the degree of sensitization to movement The movement diagram for painful passive movements is inconsistent with the palpation findings. The proportional increase in pain does not relate to movement. There is little or no relationship between the sensitized pain and any resistance encountered with movement The history does not correspond to the degree of movement restriction and symptom response to movement. Symptoms and movement restrictions are out of proportion to the extent of the injury or the stage of the disorder (maladaptive) Local treatment has very little lasting effect Grade I and I I techniques on t h eir own will not produce effective hypoalgesia Grade I I I and IV techniques may only serve to enhance nociceptive barrages to the already sensitized dorsal horn cells and higher centres if the patient still strongly links
poin to horm. Stretching, although increasing the range of movement, will not effect pain relief in proportion to the range gained
1 Primarily consider tissue-based approaches but recognize the social and psychological factors which may lead to chronicity. 2
Consider both tissue- and environ mental-based approaches to the application of mobil ization I manipulation techniques.
4. increase ranges of movement to enhance the patient's ability to improve general fitness and proprioception with the aim of maximizing the potential of exercise in regaining function after chronic disuse 5.
deal with mechanical musculoskeletal factors which may be resulting in enhanced sympathetic output and therefore maintaining the central sensitizing process.
Shacldock (1999a, 1999b) has argued for the evidence based use of manual techniques in patients who have developed central pain mechanisms as part of their musculoskeletal disorder. Shacklock's articles are
highly recommended reading for all manipulative physiotherapists who deal with patients who are suf fering from chronic pain. Shacklock (1999b) argues that, through neuroplas ticity, not only may hyperalgesia be conditioned or learned but it may also be unlearned and that learning occurs through afferent inputs which are both tissue based (nociception, proprioception) and environmen tally based (social, psychological). This, Shacklock considers, makes manual therapy particularly import ant in the treatment of pain and disability, i.e.: •
at spinal cord level manual therapy can be responsible for diffuse noxious inhibitory control including that of secondary hyperalgesia
265
266
MAITLAND'S PERIPHERAL MANIPULATION
[ manual therapy can work in altering pain through the sympathetic nervous system's ability to change afferent input changes in the brain's representation of body areas can be evoked by manipulation sensory information in response to passive movement is processed differently from active movement, showing that the two types of movement may exert different gating effects on the brain changes in motor output are a consequence of alteration in central pain mechanisms.
•
•
•
•
Shacklock (1999a), therefore, suggests that cognitive and behavioural components specific to the individual patient's problem can still be addressed through man ual therapy approaches by: helping the patient to overcome fear avoidance or loss in trust of movement 2. helping to weaken the link in the patient's mind that pain means harm 3. desensitizing or reconditioning movement to evoke 1.
stimulus reinterpretation 4. helping the patient to control responses to pain or demonstrating how to do so by, for example, progressing mobilization techniques from small to larger movements as the patient learns to control the quality and quantity of functional mobility, or by showing that more movement is possible if the patient can learn to relax tense muscles during a particularly painful movement (active or passive).
RECOGNIZA B LE SYNDROM ES t RECOGNIZABLE PAT HO LOG IES Recognizable syndromes The typical upper limb and lower limb syndromes encountered by manipulative physiotherapists are detailed in Corrigan and Maitland ( 1983) and are out lined earlier in this chapter. Each corresponding chap ter will review the typical clinical syndromes for each region. It is valuable for the manipulative physiother apist to gain experience in recognizing pain patterns or clinical profiles as many disorders respond to particu lar mobilization techniques as part of the overall man agement of such conditions. I
A
I
•
B
H
Pattern recognition is a valuable clinical reasoning strategy (Chapter 1) which will guide the novice as well as the expert in clinical decision making. An example (from Chapter 11) of clinical profiling and accompany ing clinical thinking is presented in Box 11 .14.
Hypermobility I instability this text hypermobility is used to infer an increased range of a joint (or joints) compared with the average range of movement in a given direction for that joint (or joints) in the general population. The joint may be hyper mobile in one direction whereas other movements of that joint may be of average range or even hypomobile. The hypermobility may be general in that it affects all or most joints in all or most directions. The essential part of the definition is tl1at there is full muscular control of the hypermobile range. To depict a hypermobile range on the baseline of the movement diagram, or on the same baseline as used for depicting grades of move ment on a normal joint, the line AB extends beyond point B. This is because B is defined as the 'end of the normal average range of movement'. The end of range for the hypermobile movement is suitably identified as H (Fig. 10.5). If trauma (or disease) results in loss of a ligament's ability to restrict the range of a movement that it nor mally restricts, that movement will become excessive (unstable). The important implication of these circum stances is that there will not be any muscular control of this new excessive range of movement. Without this muscular control, the joint is unstable. This kind of instability is hypermobility, but hypermobility is not necessarily this kind of instability (a cat is an animal, but an animal is not necessarily a cat). There is another form of hypermobility and another form of instability, both of which are associated with pain: In
•
The hypermobility is seen with the subluxing patella. In tlUs situation the patella has a hypermobile range of lateral displacement. When the patellofemoral articulation becomes symptomatic the 'apprehen sion test' becomes positive, i.e. if the patella is pas sively moved laterally while the tibiofemoral joint is in a relaxed extension position, a point will be reached in the range when the patient suddenly Figure 1 0. 5 hypermobil ity.
Beginning
End of normal
End of
of range
average range
hypermobile range
of movement
of movement
of movement
Movement d i ag ra m showing
Peripheral neuromusculoskeletal disorders
267
] reflexly contracts the quadriceps muscles to prevent further patellar movement. This occurs at the point when the patella, if moved any further laterally, will sublux. •
The other kind of functional instability is a pain response phenomenon, commonly seen in a painful tibiofemoral disorder. Usually, full knee extension (passively or actively) is limited by pain. This being so, when the patient walks and reaches that part of the gait that requires controlled knee extension, the patient is unable to control the position and the knee wobbles until the knee extension phase is no longer required. This kind of instability is some times referred to as 'stable instability' or 'pain alerted instability' because when the knee extension becomes painless the instability seen on walking disappears.
Treatment of such disorders i s also described in Chapter 8. Qualifying 'arthritis' is this way can help the manipu lative physiotherapist to identify which patient's dis orders can be helped by mobilization/manipulation treatment techniques and which disorders will need other approaches to their management. Such situa tions can be identified by detailed history taking and the response to treatment.
Subclinical arthritis This is an extremely difficult subject to discuss without disruption and laying oneself open to criticism. Nevertheless, it is extremely important to have some understanding of: • •
Joint locking
•
•
what it is, and how it presents with patients how it relates to arthritides what medical test results would indicate its presence what medical treatment can be used to indicate its presence what interpretations can be put on it in relation to treatment and prognosis.
This inability to move a joint normally is caused by such events as 'loose bodies' within a joint or a torn meniscus. The onset of a meniscus injury is usually one of an unguarded twisting movement; however, loose bodies may 'come and go' (usually with movement) without the patient being aware of the particular move ment(s) which cause the locking. The role of the physio therapist is to try to free the joint from the obstruction to movement by passive movement techniques. Once freed, exercise for joint support and joint-care educa tion are essential.
Because there is a recognizable pattern of both the patient's symptoms on subjective questioning, and the physical signs on the objective examination, and because the varying responses to passive movements are clear and predictable in terms of (a) the value of physical treatment and (b) the indications for specific medical treatment, the subject should be tackled.
Fractures and non-uniting fractures
Definition of title 'subclinical arthritis'
The manipulative physiotherapy application to such disorders is discussed in detail in Chapter 8 .
Arthritis Simply means that there is an inflammatory
Arthritis (qualified) 'The statement that one has to live with arthrosis seems to be a true statement. However, the pain they relate to within the same pathology is not a symptom the patient has to live with, since correlation between arthrosis and pain is non-existent' (Van Wingerden 1995). An active arthritic disease disorder that is causing pain cannot be relieved of the pain by techniques such as those described in this text. However, both post traumatic arthritis and degenerative osteoarthritis can be helped by skilled manipulative physiotherapy. Additionally, longstanding osteoarthritis which is only minimally (or moderately) uncomfortable rather than painful, but is causing activity limitations, can be helped to gain further range and thus a better lifestyle.
•
process within a synovial joint, and as the 'arthritis' is here tied to the word subclinical, the inflammation will not necessarily show itself in terms of being 'red, hot and swollen'. The word is also not saying that it is osteoarthritis or any other diagnosable arthritis dis order, such as, for example, rheumatoid arthritis. The word 'arthritis' should not be used as a syno nym for osteoarthritis. If it is used to describe to the patient what the problem is, it is also essential to explain that this is not osteoarthritis and that the patient will not be confined to a wheelchair in the future. Some people have a fear of being crippled by osteoarthritis and this fear must be allayed. This use of the word subclinical is meant to empha size that a diagnosis of 'arthritis' cannot be given on a basis of positive blood tests, of radiological changes in a joint or any other medical tests. However, it can be determined by the history of the patient's symptoms,
268
MAITLAND'S PERIPHERAL MANIPU LATION
the behaviour of the symptoms as the patient describes them, and the behaviour of the symptoms on differen tial physical examination, especially if there are any after-effects following such examination.
Presentation The symptoms felt by the patient are con stant though they will vary in intensity. Too much activity and too much rest lead to increased pain. The pain is always at the site of (often better described as being 'within') the joint. If there is any referral of symptoms, they can spread proxima �y or distally . . from the joint and they will decrease m mtensity as they spread away from the joint areas. On passive movement of the joint in any direction . there will be a 'pain-through-range' response. This pain response is heightened if the passive movement is performed while the joint surfaces are held com pressed together. These patients avoid use of the joint affected and prefer to support it in a mid-range position, yet they also choose to move it about in many directions gently and comfortingly in between periods of rest. After more prolonged periods of rest, such as during the night, patients find it more difficult to institute mov� ment as the joint feels to have stiffened; however, this stiffness soon disappears following a little movement. There is yet another aspect of pain present with this disorder. Following either examination movements, or activities that cause discomfort, there is a latent and lingering exacerbation of symptoms. This 'after-effect' may be present with other disorders but it is always present in 'subclinical arthritis'. The exacerbation lasts for a longer period with the more active disorder than with inactive arthritis. The pain of this disorder differs from that found with a more mechanical type of inflammatory disorder. The latter pain can be relieved in particular positions of rest and the position of comfort can be maintained for much longer periods without the feeling of its needing to be moved. In a likewise manner, when it does feel the need for movement, the initial stiff feeling goes much more quickly: it will probably require only three movements before it is freed. These subtle differences are important to be able to distinguish. Perhaps the experience of treating these patients is the only wa'! to be able to distinguish one from the other on the baSIS of pain alone. Experience teaches so much.
The faster the movement is performed, the greater will be the pain. Conversely, it may be possible to move through 50% of the range without discomfort, pro vided the movement is performed: • •
Symptoms
M ovements As stated above, movements in all direc tions of the affected synovial joint will be uncomfort able. It will be a 'through-range-pain' response to the movement, irrespective of whether the movement is a physiological or a passive accessory movement.
•
extremely slowly passively (not actively because this involves a degree of joint compression) in a manner that avoids any moderately firm contact of the contiguous joint surfaces.
This is in contrast to the more mechanical (this is an unfortunate term if it is taken literally) variety of arth ritis (see Symptoms above), where a moderate degree of speed or joint surface contact is not exceSSively painful. Comparing a small passive movement of the affected joint, first with the joint surfaces in their usual normal relationship, and then with compression of the joint surfaces, there are marked differences in the pain response: the slow uncompressed movement is far less painful than that felt when compression is added. Examination of movements of a joint that may be thought to have a subclinical arthritic involvement should initially be performed slowly. This avoids exacer bation that occurs from over-zealous testing. Having tested some of the movements it is possible to have an idea of the likely reaction to the examination. Armed with this information, the following test procedure of a movement will provide definite information as to how primary the inflammatory component of the disorder is. Circumstances can exist where a patient feels pain or discomfort in rhythm with oscillatory movements performed by a therapist. This is not uncommon when these movements are performed at or near the end of a range. With a subclinical arthritic disorder, oscillatory movement within range (grade II-) may be felt as a movement within the joint. However, important though this is, it is not as important as the fact that an ache within the joint will develop and it will increase in intensity as the oscillations are continued. This build-up of ache is a consistent finding with this dis order. To continue building up the ache is harmful and should therefore be avoided. However, more informa tion of importance is gained if a minimal ache is first provoked with a known number of oscillations. The movement is stopped, and time taken for the ache to subside is noted. When it has subsided, the same num ber of oscillations is repeated and the ache compared, as well as comparing the time taken for it to subside again. A favourable finding is the case if the ache is less with the second set of oscillations, or if it subsides more quickly. One point which may make it easier to understand and recognize this particular disorder is that the
Peripheral neuromusculoskeletal disorders
inflammation is primary and not secondary. In this way it is different from the inflammation (the -itis of arthritis) that occurs following a sprain or other simi lar incident. This is probably the reason why it does not recover to a pain-free stage as readily as does trau matic inflammation. Treatment response This aspect is discussed in Chapter 8 but is mentioned here to show the disorder's distinctive nature. When the disorder is in a very low grade inflammatory stage, oscillatory movements of large amplitude are used and are taken into a very small degree · of discomfort. Initially, the movements should not provoke any ache that increases in intensity or does not dissipate quickly when the movement is stopped. In the less low grade stages, movements must not provoke discomfort, or even awareness (to the patient) of a feeling of movement taking place within the joint. There must be no development of ache within the joint. Characteristically, there will be a very pleasant feeling of warmth and comfort following the correct treatment. Though this may only last from half an hour up to 2 hours at first, the feeling is one that the patient has not had previously and is not produced by any other form of physiotherapy.
management programme including medical screening and management, advice and self-management strat egies, hydrotherapy and genera! exercise programmes. Occupational therapists, social services and employ ment services will also be involved. In short, input from the whole rehabilitation team is essential.
Total joint replacement Total joint replacements are a common surgical inter vention in many degenerative, inflammatory types of osteoarthritis and in some post-traumatic situations. Although many protocols describe maintenance and improvement of joint mobility as one of the treatment objectives, they are not explicit in the use of active, assisted active (or assisted passive) or passive move ments (Moncur 1996, Atkinson et a! 1999, Trudelle Jackson et a! 2002, Thomas 2003) . Gentle passive mobilizations may complement the postoperative treatment. However, they may need an approach of 'wise action' (Jones 1997; see also Chapter 4), with the following considerations: • •
Traumatically induced arthritis
•
Such disorders may arise as a result of meniscectomy or intra-articular fractures. Arthritic changes take place within the joint prematurely due to the predisposing injury.
•
Degenerative arthritis Degenerative joint disease can develop purely as a result of wear and tear and age-related changes within the joint. However, there is another type of degenera tive arthritis that affects joints locally through what is thought to be local enzyme or autoimmune responses. This type of degenerative arthritis is progressive but, like wear and tear and traumatically induced arthritis, symptoms can be eased and ranges of move ment increased with passive movement treatment techniques.
Osteoarthritis This is the form of disease that is active and systemic and is characterized by exacerbation and remission affecting many joints. Pain and joint stiffness can be influenced with passive movement treatment tech niques during the quiet phases of the disease but patients with such disorders need a total rheumatology
•
Employ mainly accessory movements. Localization of forces should be as close as possible to the joint line. Application of forces should take place as much as possible parallel to the line through the joint surfaces. Long leverage or techniques which may move the bone around the prosthesis should be avoided (e.g. longitudinal caudad movement localized at the distal part of the tibia in knee treatment, distal part of femur in hip movement, distal part of humerus in shoulder movement). Progression of treatment is possible as described in Chapters 7 and 8.
If active movements achieve the goals of treatment, passive movements become superfluous. However, in an early phase after the operation in which the focus lies on active movement within pain-free limits, gentle passive movements may support the active movement of the patient (e.g. many patients with a joint replace ment of the hip may have difficulties with active flexion of the knee in supine lying. Gentle AP move ment, applied to the joint, may 'centralize' the hip better which then allows the patient to actively flex further into the range). In later stages, when tissue healing is nearly com plete and joint mobility seems more restricted than would be expected in this phase, passive movements may become the first treatment of choice to enhance mobility.
269
270
MAITLAND'S PERIPHERAL MANIPULATION
PROG NOS IS (DISORDERS W H IC H AR E EASY / D I FFICULT TO H EL P) The importance of making a prognosis in manipula tive physiotherapy is discussed in Chapter 8. Essentially, the manipulative physiotherapist should be able to relate certain characteristics of the presenta tion of a disorder to the potential effectiveness of mobilization/manipulation techniques. Box 10.4 com pares and contrasts those features which may make the disorder relatively easy to help (responders) and those features which may make the disorder more dif ficult to help (non-responders).
DI F F ER E NTIAL DIAG NOSIS A patient may have pain which is felt in the shoulder whereas in fact its source may lie in the cervical spine or its neuromeningeal elements. With pain in the right shoulder, the cause may even be in the gall bladder (visceral origin). The role of the physiotherapist is to determine the source of the patient's symptoms. This should include the possibility that pain is referred from the spine, from other peripheral joints, from viscera or to viscera. Examples of this are: •
A patient who feels pain in the vicinity of the insertion of deltoid which is referred from the
Disorders easy to h e l p (responders)
Disorders d i ffi cu l t to h e l p (non-responders)
A strong relationship of the patient's symptoms and
A weak relationship between the symptoms and
movement A recog nizable / typical syndrome, recog nizable / typical pathology Predominantly primary hyperalgesia and tissue-based pain mechanisms (nociception, peripheral neuro genic pain) Helpful thoughts and behaviours ('I can still do some things', 'I have found ways to get relief) Familiar symptoms which the patient recognizes as tissue based ('It feels like a b ruise') No or minimal barriers to recovery or predictors of chronicity ('yellow flags') The seve rity, i r ritability and nature of the patient's symp toms correspond to the history of injury or strain to the structures of the movement system The patient has had a p reviously favourable sampling experience of ma nipulative physiotherapy There are easily identifiable signs of impairment and activity limitatio ns which have a strong relationship to movement Patients are touch tolerant (gain relief by touch, rubbing or massage) An internal locus of control ('I just need to know how to help myself) ; locus of control is consistent The patient has realistic expectations fo r recovery which correspond to the stages in the natural history of the disorder Patie nts will resume appropriate activity and exe rcise at relevant stages in recovery
movements in the patient's mind Atypical, u n clear patte rns, syndromes or pathology Predominantly seco ndary hype ralgesia from central sensitization rather than tissue-based symptom responses Maladaptive thoughts and behaviour ('I don't think I'll ever get better', I dare not move because it always hu rts me') and other 'yellow flags' U n familiar symptoms which the patie nt has difficulty describing in sensory terms Multicomponent / complex regio nal pain syndromes Severity ir ritability and nature do not fit with the history or stage in the natural history of the disorder P revious u nfavourable sampling experiences or knowledge of manipulative therapy (' I've had manipulation before and it just makes it hurt more', ' My mate had manipulation on his shoulder and he said it was much worse afte rwards') Evidence of movement impairment but with little correspondence to the degree of activity limitation Patients are touch intolerant ('I don't like anyone touching my knee') A n external locus of control ('You a re the physiotherapist, you sort me out') or an inconsistent locus of control; patient sometimes wants help and sometimes doesn't U nrealistic expectatio ns for recovery ('I wish I would wake up and all the pain would be gone') Ongoing pain states with little change in symptoms over a long period of time
Peripheral neuromusculoskeletal disorders
271 ]
•
•
•
shoulder joint in the absence of pain in the shoulder joint. Referred pain from the hip can be felt in the knee without there being any complaint of pain in the hip. Visceral pain can be referred into areas of the musculoskeletal system. Left arm pain associated with cardiac disease is quite common.
There are other examples where referral of pain works in the opposite direction, i.e. pain can be referred to an area which the patient describes as being one of the viscera. The referral mechanism in this case is usually related to the vertebral column, such as the experience of abdominal pain referred from the lower thoracic spine. Likewise, pain can be referred into the testicular area from the hip. The manipulative physiotherapist can gain valuable information from: •
•
•
the subjective examination (localization, description of symptoms, behaviour of symptoms with movement of the part where the symptoms are present, the onset of symptoms) the physical examination (movement impairment in the region of the pain, differentiation testing of the neuromusculoskeletal structures) the response to treatment (effectiveness of local treatment).
This information will help the phYSiotherapist to decide whether or not the symptoms have their origin in the neuromusculoskeletal system and if so, what is the neuromusculoskeletal source of the symptoms (local or referred). If the symptoms are originating out side the neuromusculoskeletal system, diagnosis and management may well fall outside the physiothera pist's scope of practice and the appropriate practi tioner should then be contacted. One very useful text entitled Differential Diagnosis in Physical Therapy (Goodman & Snyder 1995) is recom mended reading and a recommended reference book. to help phYSiotherapists recognize and identify condi tions referred to physiotherapy which could be mim icking neuromusculoskeletal disorders. These conditions can be reviewed in relation to body systems and the possible sources of pain in the various body regions (e.g. shoulder pain, hip pain, groin pain). Interestingly, Goodman and Snyder (1995) put great significance on history taking and the relevant ques tions which should be asked if systemic disease is sus pected. It is not the intention of this text to detail all these questions and their interpretation but to make
the clinician aware of what their knowledge base should include and refer to the appropriate texts. Box 10.5 shows the main differences between the presentation of systemic and musculoskeletal joint pain; Figure 10.6 shows the common sites of visceral referred pain. Through thorough questioning and assessment of the relationship of symptoms to movement of the neu romusculoskeletal system, the skilled clinician will be able to identify the presence of disorders of the move ment system. However, if no relationship exists the cli nician should be aware of the possibility of symptoms being referred from systemic disease into muscu loskeletal areas such as the shoulder, hip and groin: •
Cardiovascular pain from cardiac disease referred into the chest and left shoulder (look for symptoms with exertion), arterial insufficiency presenting as hip pain (look for signs of claudication). -
Systemic •
Awa kens at night
•
Deep aching, t h robbing
•
Reduced by pressure
•
Constant or waves / spasm
•
Associated signs a nd sym ptoms: - jaundice migratory a rth ralgias skin rash fatigue weight loss low-grade fever musc u l a r wea kness cycl ic, prog ressive symptoms history of i nfection (hepatitis, streptococcosis, mononucleosis, measles)
Musculoskeletal •
Decreases with rest
•
Sharp
•
Ceases when stressful action is stopped
•
Associated signs and symptoms: usua l ly none - trigger poi nts may be accompanied by nausea, sweating
Reproduced by kind permission from Good man Et Snyder
( 1 995).
272
MAITLAND'S PERIPHERAL MANI PULATION
Perforated
Liver
duodenal ulcer Heart
Biliary colic
Penetrating duodenal ulcer
Cholecystitis,
Renal colic
pancreatitis,
Cholecystitis Pancreatitis,
duodenal ulcer
renal colic
Appendicitis
Rectal lesions
Colon pain
Fig u re 1 0.6
•
Common sites of referred pain. Reproduced by kind permission from Goodman 8: Snyder ( 1 995).
Pulmonary
-
pain in the right or left shoulder from
and general fatigue associated with endocrine and
pleurisy or Pancoast tumours (look for cough spu tum, shortness of breath, weight loss). •
Gastrointestinal/biliary
- the gall bladder referring
metabolic disease. •
may mimic musculoskeletal disorders in terms of
nausea and appetite changes), appendicitis refer
movement restrictions but patients also suffer from
ring pain into the groin area (look for fever and
general malaise and cannot reduce the pain them
altered bowel habits).
•
selves whatever they try to do. This is also the case renal disease referring pain
in metastases in the shoulder from breast and lung
into the loin and even the right shoulder (look for
tumours and metastases in the pelvis and back from
changes in urinary function), ureteral colic causing
prostate tumours. Lymphatic swellings, espeCially
pain to be referred into the hip.
in the neck, axilla and groin, should be considered
Renal and genitourinary
-
with some of the leukaemia/lymphoma patholo
Hepatic - liver abscesses can refer pain into the right
gies, as should the bone pain associated with multi
shoulder. A sense of fullness, jaundice, anorexia,
ple myeloma.
nausea and vomiting may accompany the pain and discomfort. •
- the primary tumours, especially in
bone, of the shoulder and knee (femur, tibia/fibula)
pain into the right shoulder (look for associated
•
Oncological
•
Immunological - here the typical progressive history
Endocrine and metabolic - the cramps and aching, tired
and symptomology of exacerbation and remission
limbs and trophic changes, temperature intolerance
of rheumatic disease springs to mind.
Peripheral neuromusculoskeletal disorders
References Atkinson, K, Coutts, F. & Hassenkamp, A-M. 1999. Physiotherapy in Orthopaedics - A Problem Solving Approach. Edinburgh: Churchill Livingstone Butler, D. 2000. The Sensitive Nervous System. Adelaide: NOr Group Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Medicine. London: Butterworths Elvey, R. & Hall, T. 1999. Nerve trunk pain. Physical diagnosis and treatment. Manual Therapy, 4, 63-73 Fry, H. J. H. 1986. Overuse syndromes in musicians: prevention and management. Lancet, ii, 728-731 Gifford, L. S. 1997. Pain. In Rehabilitation of Movement: Theoretical Basis of Clinical Practice, ed. J . Pitt-Brooke. London: W. B. Saunders Goodman, C. & Snyder, T. 1995. Differential Diagnosis in Physical Therapy, 2nd edn. Philadelphia: W. B. Saunders Greening, J. & Lynn, B. 1998. Minor peripheral nerve injuries - an underestimated source of pain? Manual Therapy, 3, 1 87-194 Harding, V. 1997. AppLication of the cognitive-behavioural approach. In Rehabilitation ofMovement: Theoretical Basis of Clinical Practice, ed. J . Pitt-Brooke. London: W. B. Saunders Hunter, G. 1994. Specific soft tissue mobilization in the treatment of soft tissue lesions. Physiotherapy, 80, 1 5-21 Jones, M. A. 1997. Clinical reasoning: the foundation of clinical practice. Part 1. Australian JOllrnal of Physiotherapy, 43, 1 67-170 Lewis, J., Green, A. & Dekel, D. 200 1 . The aetiology of
Maitland, G . D . 1992. Neuro/musculoskeletal Examination and Recording Guide, 5th edn. Adelaide: Lauderdale Press Moncur, C. 1996. Physical therapy management of the patient with osteoarthritis. In Physical Therapy in Arthritis, ed. J. M. Walker & A. Helewa. Philadelphia: W. B. Saunders Sahrmann, S. A. 200 1 . Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby Shacklock, M . 1999a. The clinical application of central pain mechanisms in manual therapy. Australian Journal of Physiotherapy, 45, 215-221 Shacklock, M. 1999b. Central pain mechanisms: a new horizon in manual therapy. Australian Journal of Physiotherapy, 45, 83-92 Slater, H. & Wright, A. 1995. An investigation of the physiological effects of the sympathetic slump on peripheral nervous system function in the upper limb. In Moving in on Pain, ed. M. Shacklock, pp. 1 74-184. Sydney: Butterworth-Heinemann Thomas, K. 2003. Clinical pathway for hip and knee arthroplasty. Physiotherapy, 89, 603-609 Trudelle-Jackson, E., Emerson, R. & Smith, S. 2002. Outcomes of total hip arthroplasty: a study of patients one year postsurgery. Journal of Orthopaedic and Sports Physical Therapy, 32, 260-267 Van Wingerden, B. A. M. 1995. Connective Tissue in Rehabilitation. Vaduz: Scirpo Verlag Watson, J . 1986. Pain and nociception - mechanisms and modulation. In Modern Manual Therapy of the Vertebral Column, ed. G. Grieve. Edinburgh: Churchill Livingstone Wright, A. & Sluka, K 200 1 . Non-pharmacological
subacromial impingement syndrome. Physiotherapy, 87,
treatments for musculoskeletal pain. Clinical Journal of
458-469
Pain, 17, 33-46
273
275
Chapter
11
The shoulder and shoulder girdle complex
THIS CHAPTER INCLUDES: • • •
•
•
Key words for this chapter Glossary of terms for this cha pter A review of the pain-generating structures of the shoulder / shoulder girdle Subjective exa m ination of the shoulder/shoulder girdle An integrated approach to the physical exam i nation of the shoulder/shoulder girdle
KEY WORDS Glenohumeral, acromiohumeral,
GLOSSARY OF TERMS Adhesive capsul itis - a disorder of the glenohu meral joint of u n known aetiology which is characterized by painful and gradua l ly progressive restriction of active and passive glenohu meral joint motion (Cleland Et Dura l l 2002). Such d isorders tend to run a long and protracted course and eventually become self lim iting. Brief appraisa l - a selection of active movement tests of a joint or region of the spine which should reproduce symptoms or produce comparable signs or selected active
•
•
Exam i nation and treatment techniques The clinica l profiles of common shoulder / shoulder gird le d isorders: frozen shoulder / a dhesive ca psu litis painful stiff/ pseudo frozen shou lder glenohu meral osteoarthritis shou lder i nstability
•
fractures of the neck of h u merus subacromial impingement acromioclavicular d isorder m i n i m u m i nterm ittent m i nor shoulder pain A case study of a patient with a stiff pai nful shoulder.
acromioclavicular, sternoclavicular, scapulothoracic, costal joints,
brachial plexus, rotator cuff.
movement tests to screen a joint or region of the spine in order to exclude it from i nvolvement in the disorder. Functional demonstration - a demonstration of a fu nctional activity (or injuri ng movement), by the patient, which causes difficu l ty or which reproduces the symptoms reliably. Functionally demonstrated movements can then be differentiated to help locate the source of the symptoms. Furthermore, the fu nctional demonstration can be used as a potential treatment movement and
as a n asterisk to use in reassessment. If necessary tests - the use of, for exa m ple, combined movements, susta i ned / repeated movements or movements at speed when routine active function a l testing has not been sufficient to reproduce symptoms or produce comparable signs. Interfaces - structures such as bony tunnels, fibro-osseous tunnels, m uscles and tendon edges adjacent to or through which nerves pass. Locking position - a functional locking of the shou lder when the
276
M A IT LA N D'S P E R I PH E RA L M A N I PU LATI O N
shoulder is a bd ucted with mainta ined medial rotation ; slightly below the median coronal plane there reaches a point i n the abduction where the shoulder can not be a bd ucted, rotated or moved a nteriorly. Thus i n effect the shoulder is locked. Such a fu nctional 'corner' position is often symptomatic in m i nor shoulder disorders and mobilization i nto a pai nful locking position should be considered if m i nor symptoms or
i m pa i rments of the shoulder a re not resolving. Quadra nt - a functional movement of the shoulder which can be used to detect and treat m i nor or less obvious painfu l restrictions. The quadrant is that position, a pproximately 30· lateral to the fu lly flexed shoulder position, where the person's u pper arm has to move a nteriorly and a utomatica lly rotate to achieve the fu lIy flexed position.
MOVEMENT SYSTEM IMPAIRMENTS OF THE SHOULDER/SHOULDER GIRDLE COMPLEX - STRUCTURES AT FAULT
The clinical presentation of movement disorders of the shoulder/shoulder girdle complex (Fig. 11.1) should be interpreted in the light of knowledge about the structure and movement potential of this region. The innervation and potential generation of symptoms
Subacrom i a l i m p ingement - a variety of conditions (independent or i n combinations) which manifest as a nterior and anterior-Iateral su perior shoulder pain. The conditions occurs due to pathology of one or more structu res of the subacromial space and are characterized by painful loss of shoulder function, especially over head activities (Lewis et al 2001).
(pain, stiffness, discomfort, etc.) in and around the shoulder should also be considered. The clinician should consider the role of the articu lar, neural and muscular structures in this region and how they interrelate to affect shoulder/shoulder gir dle movement when impaired. Consideration should also be given to the influence of other body systems in generating symptoms and influencing movement, including visceral referred
�-- Sternoclavicular joint Acromioclavicular joint
�--
Clavicle
L-�-- Acromiohumeral joint Scapula ---I-+-++P",,"Scapulothoracic ---f--f---i-f-f
Figure 1 1 . 1
The shou lder co m plex.
...y"...-
,+y-t- Glenohumerai joint
The shoulder and shoulder girdle complex
pain (Chapter 10) and vascular impairment (e.g. the subclavian artery in the thoracic outlet).
Articular structures (synovial, non-synovial) Glenohumeraljoint The glenohumeral joint has large amplitudes of both physiological and accessory movement. These occur in a greater number of directions than any other joint in the body (Maitland 1991). When the joint is disordered this will be reflected in the answer the patient gives to Question 1 (What is your main problem?). One would expect that the symptoms which the patient is experi encing from a disordered glenohumeral joint will be accompanied by a variety of functional limitations of the shoulder, such as taking off a pullover, reaching above head height and putting the hand up the back. The most commonly diagnosed disorders of the glenohumeral joint are: frozen shoulder or adhesive cap sulitis, which is characterized by painful and gradually progressive restriction of active and passive gleno humeral joint motion (Cleland & Durall 2002) and osteoarthritis, which according to Bland (1983) is char acterized by pain, deformity, limitation of motion and slowly progressive disability. Other disorders which affect the glenohumeral joint are fractures of the humerus, painful stiffness usually as a consequence of an injury or strain to the joint structures and minimal intermittent pain and instability, which was defined by Maitland (1986) as an excessive range of abnormal movement for which there is no protective muscular control. -
The glenohumeral joint receives its articular branches from the axillary, musculocutaneous, suprascapular and subscapular nerves (C4-C7). The clinical rele vance of this knowledge helps the physiotherapist to recognize the potential for the glenohumeral joint to become symptomatic when disordered, to recognize potential associated areas of symptoms and to recog nize that the shoulder can be a site of referred symp toms from other sources. During the subjective examination, while trying to establish whether the patient is experiencing pain coming from the glenohumeral joint, it is often useful to grasp around the head of the humerus so that the fingers on one side of the glenohumeral joint can press into the space between the humerus and the glenoid cavity towards the thumb, which can press in on the opposite side of the joint. At the same time the physio therapist can ask the question, 'Is the pain in (meaning deep within) here?' To emphaSize the 'within' aspect of the question, the fingers and thumb gently rock the head of the humerus backwards and forwards. It may be necessary to support the acromioclavicular area with the other hand (Fig. 11.2). The emphaSiS with which the patient is able to say 'yes' or 'no' to the ques tion has very real value. Pain from the glenohumeral joint can refer both upwards, even as far as the base of the neck (Fig. 11.3a), or downwards, even as far as the forearm and occasionally into the hand. The referred arm pain is commonly less intense in the distal area (Fig. 11.3b). There are two other common areas of referred pain from the glenohumeral joint, usually associated with Figure 1 1 .2 Sites of pai n within the glenohumeral joint.
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Figure 11.3 S i tes of pai n : (a) referred into the neck; (b) referred into the arm.
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(a)
chronic disorders: one is a patch of pain near the insertion of the deltoid muscle (Fig. ll.4a) and the other is a band of pain around the arm at that level (Fig. ll.4b). The physiotherapist should always consider that a patient may have different kinds of shoulder pain and different yet closely associated sites (i.e. the different pains may be constant or movement related; they may be sharp or dull, vague or localized). The physiotherapist must also appreciate that the patient's shoulder disorder may present with different behaviours of pain and different provoking factors for
the pain. By this it is meant that the symptoms may be constant and unvarying or constant but exacerbated by certain movements or activities and require a calcul able period of time to settle. The patient may only have symptoms following vigorous activity and lying on the shoulder at night or it may be a sharp pain which is only felt with sudden unguarded movement. The list goes on but it is clear that there is a relationship between these scenarios and the clinical groupings proposed in Chapter 8. If the glenohumeral capsule and its supporting lig aments are impaired and painful the degree of painful
The shoulder a nd shoulder g ird le complex
Figure 11.4 Sites o f pain : (a) cOmmon patch of pai n ; (b) a band around.
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�\�/ movements may well correspond to the capsular pat tern of painful restriction proposed by Cyriax and Cyriax (1983), i.e. activities involving lateral rotation of the shoulder will be more painful than activities involving abduction of the shoulder, which will be more painful than activities involving medial rotation of the shoulder. The degree of pain and restriction should correspond proportionally to the degree of injury or pathological activity and the stage in the nat ural history of the disorder. Correspondingly, if the capsular structures are impaired, the patient or physio therapist will often, with care, be able to position the
shoulder either in a pain-free/discomfort-free position or a position which gives as much relief as is possible in view of the degree of inflammation. If the glenohumeral joint articular cartilage has full thickness defects exposing the C fibres in the subchon dral bone, shoulder movements will be accompanied by pain, stiffness and sometimes crepitation through range. Commonly, patients will complain of a deep ache within the joint while lying on the shoulder at night. In other words, excessive loading and compres sive forces on the articular cartilage/subchondral bone will exacerbate the patient's symptoms.
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Glenohumeral joint disorders resulting in impair ment of movement often follow recognizable courses from onset to resolution. Typically the true frozen shoulder will begin spontaneously and follow a pro tracted course of severe pain, pain and stiffness, and stiffness alone. Osteoarthritic glenohumeral joints will present with gradually developing symptoms which are aggravated episodically by unusual or heavy activ ity. Fractures of the humerus will have a traumatic/ injurious onset. Glenohumeral joints which become painful and stiff will have their origins in injurious mechanisms or overuse strain which often emerge only after careful questioning of the patient. Instability of the glenohumeral joint will similarly develop as a result of injury (recurrent dislocation), predisposing factors (tight glenohumeral posterior capsule) or activ ities (baseball pitching). The physiotherapist assessing a patient with shoul der pain should be aware of other conditions which may be responsible for such symptoms, especially if there appears to be little or inconsistent relationship between the patient's shoulder pain and movement of the shoulder. If this is the case then the physiotherapist should be aware that ischaemia of cardiac muscle can present as pain in the left shoulder. Symptoms of car diac origin are likely to be exacerbated by physical exertion rather than movement and may be accompan ied by shortness of breath and cyanosis. Visceral organs such as the gall bladder may refer pain into the shoulder and are likely to be accompanied, after eating certain foods, by indigestion and flatulence. Circulatory disturbance as occurs with subclavian artery compression is likely to be accompanied by symp toms of circulatory compromise in the upper limb. Metabolic and oncological (Pancoast tumours) disease should also be considered as potential generators of symptoms in the shoulder / shoulder girdle regions (Chapter 10).
Acromiohumeral complex The acromiohumeral 'joint ' is synonymous with sub acromiaL impingement syndrome, rotator cuff pathoLogy and subacromiaL bursitis, all of which can present with pain at the point of the shoulder under the acromion (anterior, lateral, posterior) and most commonly with painful arcs of movement. The joint space includes the subacromial bursa and the supraspinatus tendon, and as a joint, it moves whenever the glenohumeral joint moves. Therefore any glenohumeral joint technique will apply equally to the acromiohumeral joint (except glenohumeral compression techniques). Disorders of this complex are usually due to a reduced subacromial space (averaging 9-10mm) and
are often multifactorial (Lewis et al 2001) with such factors as anatomical variations in the anatomy of the acromion process, disturbance in the union of acromial centres of ossification, rotator cuff overuse or degener ation, failure of the rotator cuff to stabilize the head of the humerus, calcification of the supraspinatus ten don, loss of capsular restraint, restriction of the gleno humeral capsule, functional scapular instability and postural alignment faults, all potentially contributing to the development of subacromial impingement. Acromiohumeral disorders, therefore, will be aggra vated by functional situations which reduce the sub acromial space, such as working with the arms at head height, the cocking position used in throwing (Schieb 1990) or overhead activities where posture is particu larly poor. Weakness often accompanies subacromial pain as a result of the rotator cuff muscles being dam aged, inflamed, degenerate or pain inhibited. The onset of acromiohumeral disorder will relate to the mechanisms which initiate the impairment of the structures within and related to the subacromial space. For example, the patient will relate trauma to the rota tor cuff with a specific injuring movement or activity such as a fall backwards onto an outstretched arm or a particularly vigorous throw of a cricket ball. Anatom ical variations and postural faults may result in a gradual or spontaneous onset of symptoms as the body's ability to compensate eventually starts to fail. Recovery is often slow due to the critical vascular zone in this region and complete rupture of the rotator cuff muscles may well require surgery when conservative means do not result in the resolution of the patient's impairments and activity limitations. Recurrences are dependent on the success of the physiotherapist in dealing with contributing factors such as postural align ment faults, muscle imbalance or restriction of move ment at associated joints such as the glenohumeral and acromiohumeral joints and the cervicothoracic spine. All examination and treatment techniques which are described for the glenohumeral joint also apply to the acromiohumeral articulation. This should include the quadrant and locking positions which must be clear and pain free if the acromiohumeral joint is not to be considered as a source of the patient's symptoms.
Acromioclavicularjoint The acromioclavicular joint functions to allow the acromion and therefore the entire scapula to glide for wards and backwards and to rotate on the clavicle (Peat 1986). The clavicle itself moves upwards, down wards, backwards and forwards or in combinations of these. The upward and downward movement of the clavicle is accompanied by posterior and anterior
The shou l der and shoulder girdle complex
rolling. Movement at the acromioclavicular joint, there fore, occurs during nearly all movements of the arm. Squeezing the spine of the scapula and the clavicle together is one movement which is often symptomatic when the acromioclavicular joint is disordered. Other passive movements anteroposteriorly, pos teroanteriorly, longitudinally and rotationally about the long axis of the clavicle, if impaired, may influence movement of the shoulder in any arm position. These accessory movements may produce symptoms if they are performed with the joint surfaces compressed. They may also produce a different, but relevant, clin ical response if they are performed directly on the joint line or on the acromion rather than the clavicle. The manipulative physiotherapist should also consider the use of glenohumeral joint flexion (and other gleno humeral movements) as a technique to be used in the treatment of acromioclavicular joint disorders. The acromioclavicular joint receives its articular branches from the suprascapular and lateral pectoral nerves which originate mainly from the C4 segmental level. This joint is prone to degenerative changes, sublux ation and involvement in fractures of the clavicle. Damage to the acromioclavicular joint may also encroach into the subacromial space and may contribute to the development of acromiohumeral disorders. Symptoms generated from the acromioclavicular joint will present as pain and stiffness, locally, over the joint line or deep within the joint depending on whether the intra- or periarticular part of the joint is disordered (Fig. 11.5).
pain
Fig ure 1 1 .5
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Acromioclavicular and sternoclavicular pain.
Pain i s often generated when the joint is put under strain such as lifting and carrying activities under load, or while lying on the shoulder at night. Painful horizontal adduction (flexion), horizontal extension and end-of-range painful arcs of movement are also common, especially in flexion or during the hand-behind-back movement. Onset and progression of acromioclavicular symp toms depend on the mechanisms involved. These may include traumatic subluxation, or gradual stiffening and increasing ache due to degenerative changes. Spontaneous disorders of this joint have thickened soft tissue over the superior joint line and in the acromio clavicular space irrunediately medial to the articula tion. Acromioplasty is a common procedure when degeneration of the joint does not respond to conser vative management.
Sternoclavicularjoint The sternoclavicular joint enables movements which resemble those of a ball and socket joint rather than a plane joint (Peat 1986). Consequently, roll, spin and slide of the clavicle in relation to its intra-articular disc and sternal articular surface takes place during move ment of the arm. The available passive movements of the joint which contribute to its ideal functioning are longitudinal, posteroanterior, anteroposterior and rota tory movements with the arm in any functional pos ition. All these movements can also be assessed and treated with the joint surfaces compressed together. The sternoclavicular joint is often one of the first joints affected in ankyLosing spondylitis and will be com promised when the clavicle is fractured, when the ster num has been fractured or incised as in open heart surgery, and when significant structural or postural deformities are present, Scoliosis being one such deform ity. This joint, however, when stiff or stiff and painful (Fig. 11.5) is often a contributing factor or cause of the source of movement impairment in other parts of the shoulder complex, rather than the patient's main source of symptoms. Therefore all components of the shoulder complex need to be examined when a stern oclavicular disorder is present and vice versa, i.e. the sternoclavicular joint should be examined as a poten tial contributing factor to any disorder of any of the other parts of the shoulder complex. The sternoclavicular joint receives its articular nerve supply from the supraclavicular and subclavian nerves which stem primarily from the C3 segmental level. Progressive exacerbations of pain, stiffness and accompanying inflammation in this joint, along with exacerbations and remissions of back and hip pain,
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may b e early clues indicating evidence o f ankylosing spondylitis. Otherwise, unless injured, impairment of the sternoclavicular joint manifests along with the development of other shoulder symptoms. One excep tion to this is the joint's tendency to become hyper mobile and unstable (e.g. in competitive swimmers). The hypermobility is not usually a problem in itself unless the joint becomes symptomatic. Even so, pain relieving passive mobilization techniques can be just as effective whether the joint is hypermobile (unstable) or not.
Scapulathoracic articulation The scapula has the freedom to move around the thorax to enhance the potential range of movement available at the shoulder/shoulder girdle. Passively the scapula can be elevated, depressed, protracted, retracted, rotated and tilted as well as moved in any combination of the above with the arm in any position. The scapulothoracic articulation is involved and therefore its movement can be restricted if there has been bony injury to the scapula, injury and shortening of serratus anterior, rhomboids, trapezius and other scapular muscles, and deformity or injury of corres ponding ribs. Scapulothoracic mobility restrictions often occur due to adaptive shortening as a consequence of the long protracted immobility caused by adhesive cap sulitis. On the other hand, impairment of dynamic functional stability of the scapula during arm move ments can be a major cause of the development of
painful movement-related conditions of the gleno humeral, acromiohumeral and clavicular joints and the cervicothoracic spine.
Costovertebral, costotransverse, chondrosternal and costochondral joints Pain and stiffness originating in the upper ribs, espe cially the first rib, can have an influence on the ideal mobility of the shoulder/shoulder girdle region. The first rib is attached to the clavicle at its medial end by the costoclavicular ligaments. The ribs can be moved passively either at their vertebral end (via the rib angle) or at their chondrosternal end. The first rib can also be moved longitudinally via its superior surface (Maitland et al2001). Involvement of the first rib may present as pain in the area of the supraclavicular fossa with radiation of aching down the medial aspect of the upper arm and forearm reaching as far as the little finger (Fig. 11.6). Full elevation of the arm is likely to be limited by pain and stiffness in these areas. Via the attachments of the rib to T1 and the attachment of the scaleni muscles from the first rib to the cervical transverse processes, neck movements may also be limited by pain and stiff ness in the area of the first rib. The close proximity of the brachial plexus and the subclavian artery to the thoracic outlet region may give rise to the clinical presentation of compromise or irritation of these structures, i.e. signs of neural mechanosensitivity or signs of a vascular nature in the upper limb may be present.
Figure 1 1 .6 syndrome. Pain from first rib syndrome
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Pain from fi rst rib
The shoulder and shoulder g ird le complex
Cervicothoracic spine
The consequence of pain and stiffness due to injury, strain, or postural adaptation is likely to be a first rib which is high and tight when palpated underneath the upper fibres of the trapezius (Fig. 11.7). The first rib will also be painful and stiff when moved passively at its vertebral end, its chondrosternal end or longitudi nally via its superior surface. The physiotherapist should also be aware that the common anomaly of cervical rib can also present in a similar way and will need to be confirmed radiograph ically, especially when vascular and or neurological symptoms are predominant.
Figure 1 1 .7
Palpation of the first rib u nder the trapezius.
(a)
Figure 1 1 .8
Involvement of the cervicothoracic spine interverte bral motion segments should be considered in all dis orders of the shoulder. Actual or potential movement impairment in these regions of the spine can con tribute mechanically to the ranges of movement avail able in the shoulder, as well as physiologically to pain perceived in the shoulder but referred from the cervi cothoracic spine structures. Disorder of the cervicothor acic spine often results in movement restriction of the shoulder due to the presence of neurophysiological reflex arc. Mechanical irritation of the cervical or thor acic sympathetic ganglia may enhance sensitivity of nerves, resulting in further aching and heaviness in the shoulder and arm (Butler 2000). Pain felt posteriorly in the upper arm (Fig. 11.Sa) is more commonly cervicothoracic in origin than gleno humeral; pain felt in the area medial to the scapula is also more likely to be cervical or thoracic in origin (Fig. 11.Sb). Similarly pain felt in the supraspinous fossa, in the absence of any glenohumeral pain, is more likely to be of cervical origin (Fig. 11.Sc). When pain, paraesthesia or dysaesthesia are of a non-segmental or stocking distribution, there is the pos sibility of a causal relationship from the thoracic spine at approximately the junction of the superior and mid dle thirds of the thoracic spine (Fig. 11.9). The physiotherapist may well discover that symp toms generated from outside the shoulder complex present with inconsistencies when there is an attempt to relate the symptom behaviour and history to the
(b)
Sites of pai n : (a) posterior a rm pai n ; (b) pain medial to scapula; (c) supraspinous fossa pain.
(e)
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Figure 1 1 .9 Sites of pain : stocking distribution of pain or pa raesthesia .
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;
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recognizable patterns usually evident when the move ment system structures of the shoulder region are impaired. For example, the patient's shoulder pain may come on during prolonged sitting rather than when the arm is moving and the symptoms may have arisen in line with neck pain and stiffness rather than after any injury or strain to the shoulder.
Elbow The elbow joint should be briefly appraised as a poten tial cause of the source of strain of structures in the shoulder/shoulder girdle region (Chapter 12).
Neural structures Evidence suggests that the cervical dura, the cervical nerve roots, the brachial plexus and the peripheral nerves around the shoulder respond and adapt to movement of the head, neck and upper limb (Breig 1978, Elvey 1988). Greening and Lynn (1998) have also presented evidence suggesting that chronic constric tion of nerve connective tissue produces mechanosen sitivity of the nerve resulting in diffuse dysaesthetic limb symptoms. Painful restrictions of shoulder movement, there fore, could have their origins in these neural mechano sensitive mechanisms (stretch, compression, ischaemia, friction).
suspected if pain has no localizing value. This is the case when mechanosensitivity of the cervical dura presents as diffuse non-segmental arm pain (Butler 2000) which may well be present and aggravated by arm movement. Other mechanical factors such as lengthening of the canal in slumped sitting positions will enhance dural mechanosensitivity. Such factors are often recognized by the patient as triggers which increase the symptoms.
Nerve root pain Butler (2000) has presented evidence which suggests that nerve root irritation in the cervical spine results in 'signature zones' for pain, paraesthesia and other signs of impaired nerve conduction. These signature zones (Fig. 11.10), along with their nature of onset and their relationship to mechanical irritation of the nerve roots, can be useful guidelines to identifying shoulder pain and restricted movement due to nerve· root lesions. Clinical evidence has shown that shoulder movements will be influenced by, or influence, nerve root pain. Take, for example, the tendency of patients with C5 nerve root lesions to seek relief by placing the arm above the head, or those patients with C8 nerve root lesions whose arm symptoms are aggravated if the shoulder girdle is allowed to depress.
Brachial plexus lesions and peripheral nerve injury Dural pain More specifically, Cyriax and Cyriax (1983) said that involvement of the nervous system should be
It is important to be aware of the relationship between the shoulder and the shoulder girdle and the brachial plexus and peripheral nerves. Knowledge about the
The shoulder and shoulder girdle complex
Neurodynamic testing (Butler 2000), nerve palpa tion and neurological testing for altered nerve conduc tion will serve to identify components of shoulder movement disorders which are due to mechanosensi tivity of the nervous system structures.
Neurom uscula r structures
C6 C7
L1 L2 L3
L4
L5
Anterior Posterior Figure 1 1 .1 0 The nerve root 'signature zones'. Reproduced by kind permission from NOI Group Publications, Adelaide.
cutaneous supply of the individual peripheral nerves (e.g. supraclavicular, suprascapular, axillary, musculo cutaneous, median, radial and ulnar nerves) may also help in the interpretation of pain patterns around the shoulder and upper limb (Fig. 11.11).
Interfaces There is clinical value in knowing the sites around the shoulder where the dura, the nerve roots and the per ipheral nerves are vulnerable to mechanical or physio logical compromise. These sites are, more often than not, the sites where pathology has developed or minor nerve injury is likely to occur. They include the inter vertebral foramen, the spinal canal, the scaleni muscles, the first rib / cervical ribs, the coracoid process, the clavicle, the suprascapular notch and the head of the humerus.
Rotator cuff muscle impairment has already been mentioned as an important factor in the development of subacromial impingement. Adaptive shortening of the scapular muscles has also been considered as a fac tor in the presence of stiffness of the scapula in relation to the thorax. In 1986 Maitland described the import ance of dealing with muscle imbalance in patients with low back pain and in 1991 highlighted the role of stretching of contracted or fibrosed muscle tissue in the management of movement-related neuromuscu loskeletal disorders. Muscle tissue around the shoulder can be respon sible for symptom production as is highlighted by the trigger point and referred pain charts related to spe cific muscles (Fig. 11.12). Disorders of muscle causing painful shoulder movement will often present as abnormalities in quality rather than quantity of move ment. There will also be a discrepancy in the active range of movement and the range available when the shoulder is moved paSSively. Weakness will also be a common symptom. The physiotherapist must ques tion the patient and examine them to such a degree that it is clear that the weakness is due to pain inhib ition, disuse atrophy or neurological deficit. Analysis of the dynamic functional stability of the shoulder is beyond the scope of this text. Sahrmann (2001) is the companion text which highlights the clinical value of identifying and dealing with muscle imbalance-related movement impairments around the shoulder.
The in terrelationship of shoulder movement related disorders It is rare that only one movement system component is responSible for a patient's shoulder pain. Clinical sci ence reveals that there is a close relationship between the articular, muscular and neural structures around the shoulder. The relationship between joint and muscle Guanche et al (1995), using a feline model, found that stimulation of the anterior and inferior articular branches to the shoulder joint elicited EMG activity in biceps, sub scapulariS and supraspinatus muscles. Likewise, stimu lation of the posterior articular nerve elicited EMG
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(a)
----S - upraclavicular, C.3,4-----+.k----- Upper lateral cutaneous of arm, t,;.�I.ti ----+ \-\------lntercostobrachial,T.2-----t--oM
Medial cutaneous of forearm, C.B,T.1 /+---- Medial cutaneous of arm, C.B,T.1-----, Lower lateral cutaneous of arm, C.5,6
//ffh'+f-+--- Lateral cutaneous of forearm, C.5,6 ---f-
r-f----- Palmar branch of median N-- - - Palmar branch of ulnar /�-.,.!f-*+--- Superficial branch of radial, C.7,B ----r,-"
.'b-- --- Ulnar, C.B,T.1 -----r'-,.1�� Median, C.6,7,B ------+,-/f-
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