process approach oslo 12 notes
TRANSCRIPT
-
7/31/2019 Process Approach Oslo 12 Notes
1/69
Prof. Eyal Lederman DO PhDProf. Eyal Lederman DO PhD
Process approach in
physical therapies
CPDO LtdCPDO Ltd
www.cpdo.netwww.cpdo.net
[email protected]@cpdo.net
-
7/31/2019 Process Approach Oslo 12 Notes
2/69
Process Approach
Co-create with the patient environments in which their
recovery can be optimised.
Look at the patients underline processes and match the
intervention according to these needs
-
7/31/2019 Process Approach Oslo 12 Notes
3/69
Why do we need a new model?
-
7/31/2019 Process Approach Oslo 12 Notes
4/69
Physical therapies: alignment to a structuralPhysical therapies: alignment to a structural--orthopaedicorthopaedic
modelmodel
Conceptual model for musculoskeletal health
A model for how the body fails
Structural observational and diagnostic procedures
Recovery is associated with structural modifications
Structural-physical treatment
-
7/31/2019 Process Approach Oslo 12 Notes
5/69
Utopian view of the body
Optimum structure = optimum functionAlso
Optimum control = optimum function
-
7/31/2019 Process Approach Oslo 12 Notes
6/69
Technotopia
MechanicalMechanical hardwarehardware idealsideals
ControlControl softwaresoftware idealsideals
-
7/31/2019 Process Approach Oslo 12 Notes
7/69
Asymmetry within the pelvic structures can
lead to a cascade of postural
compensations throughout the axial spine,
predisposing persons to recurrent somatic
dysfunction and decreased functionality
Juhl J et al Prevalence of Frontal Plane Pelvic Postural Asymmetry Part 1. J. American Osteopathic Association 104(10):411-
421 2004
Utopian view of the body
-
7/31/2019 Process Approach Oslo 12 Notes
8/69
Postural appearance: socialPostural appearance: social--cultural constructs of healthcultural constructs of health
Pretty = healthy, good, resilientPretty = healthy, good, resilient
Unsightly = unhealthy, bad, weak, injury proneUnsightly = unhealthy, bad, weak, injury prone
-
7/31/2019 Process Approach Oslo 12 Notes
9/69
No association between structure, biomechanics
and LBP
Trunk asymmetry, thoracic kyphosis and lumbarlordosis in teenagers and developing LBP in adulthood
(Poussa MS 2005)
Elevation of one shoulder, elevation of one hip, and
deviation of the spine from the midline of the body to
LBP & neck pain (Dieck GS, 1985)
Low muscle strength, low muscle endurance,
or reduced spinal mobility and erector spineapairs imbalances during extension
(Hamberg-van Reenen HH 2007 & Reeves PN
2006)
Lumbar lordosis (Norton BJ 2004).
Spinal scoliosis (Christensen ST 2008 syst. rev.)
Increased lumbar lordosis and sagittal pelvic tilt on back
pain during pregnancy (Franklin ME 1998)Differences in regional lumbar spine angles or range of
motion (Mitchell T, 2008)
Pelvic obliquity and the lateral sacral
base angle pelvic asymmetry
(Fann AV 2002 & Levangie PK 1999)
Inflexibility of the lower extremities or leg length
discrepancy (Nadler SF 1998)
Hamstrings and psoas tightness (Hellsing, 1988)
Correcting foot mechanics have noeffect on preventing back pain (Sahar
T, et al, 2007)
Lederman E 2010 Fall of the
postural-structural-biomechanical
model in manual and physical
therapies: exemplified by LBP.
CPDO online journal.
www.cpdo.net
-
7/31/2019 Process Approach Oslo 12 Notes
10/69
Disparity between pathomechanics and LBP
No corrolation:
Facet degeneration (n=160)
Spina bifida,Transitional lumbar vertebra,
Spondylolysis / spondylolisthesis
Modic changes
Kalichman L, et al Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976).
2008 Nov 1;33(23):2560-5.
van Tulder et al 1997, syst. review, Luoma, 2004; Brooks et al 2009
Kalichman L, et al. 2010 Changes in paraspinal muscles and their association with low back pain and spinal degeneration:
CT study. Eur Spine J. Jul;19(7):1136-44
Keller A, et al 2011 Are Modic changes prognostic for recovery in a cohort of patients with non-specific low back pain? Eur
Spine J.Aug 12
-
7/31/2019 Process Approach Oslo 12 Notes
11/69
Postural-behavioural factors
Lack of association:
Prolonged: standing, bending, twistingAwkward postures (kneeling orsquatting)
Sitting posture at workProlonged sitting at work / homeRecreational sports activities
(Hartvigsen et al 2000 syst. review; Chen et al 2009 syst. review; Bakker et al 2009 syst. review; Roffey et al 2010 syst. review; Wai
et al 2010, syst. review).
-
7/31/2019 Process Approach Oslo 12 Notes
12/69
Bishop MD, et al 2011 Magnitude of spinal muscle damage is not
statistically associated with exercise-induced low back pain intensity.Spine J. Dec;11(12):1135-42.
Disparity between symptoms and pathology
-
7/31/2019 Process Approach Oslo 12 Notes
13/69
Disparity between symptoms and pathology
TimeTime -- weeks.. months.. yearsweeks.. months.. years
PathologyPathology
SymptomsSymptoms
Carragee, E et al 2006 Does Minor Trauma Cause Serious Low Back Illness? Spine. 31(25):2942-2949
Videman T 2006 Determinants of the progression in lumbar degeneration: a 5-year follow-up study of adult male
monozygotic twins. Spine. Mar 15;31(6):671-8
Batti MC 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A study relating lifetimeexposures and magnetic resonance imaging findings in identical twins. Spine. 1995 Dec 15;20(24):2601-12
-
7/31/2019 Process Approach Oslo 12 Notes
14/69
Number of MRI
abnormalities
PRR (95% CI) [adjusted for treatment and other confounders]
Any pain Disabling pain
0 1 1
1 0.8 (0.6-1.1) 0.9 (0.4-2.0)
2 0.9 (0.7-1.1) 0.9 (0.4-2.0)
3 0.9 (0.7-1.1) 0.9 (0.4-1.9)
4 0.8 (0.8-1.2) 1.8 (0.9-3.6)
McNee P, et al 2011 Predictors of long-term pain and disability in patients with low back pain investigated by magneticresonance imaging: a longitudinal study. BMC Musculoskelet Disord. Oct 14;12:234.
Anomalies examined:Disc herniation (protrusion, extrusion or
sequestration)Nerve root deviation or compressionDisc degenerationHigh intensity zonesN=240
Disparity between spinal pathologies & LBP
-
7/31/2019 Process Approach Oslo 12 Notes
15/69
Disparity between spinal pathologies &
LBP
Karppinen J, et al 2001 Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. Spine. Apr 1;26(7):E149-5
Masui T, et al 2005 Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech.Apr;18(2):121-6.
Degree of disc displacement, nerve rootenhancement or nerve compression notcorrelated with pain level or disability
N=160
-
7/31/2019 Process Approach Oslo 12 Notes
16/69
SherSherJSJS et al Abnormal findings on magnetic resonance images of asymptoet al Abnormal findings on magnetic resonance images of asymptomatic shoulders.matic shoulders. J Bone JointJ Bone Joint SurgSurg Am.Am. 1995 Jan;77(1):101995 Jan;77(1):10--5.5.
In all age groups, 34% had partial or full rotator cuff tearsThe frequency of full-thickness and partial-thickness tears
increased significantly with age:
60 yrs +, had 54% (28% full tear, 26% partial)
40-60 yrs, (4% full tear, 24% partial)
19-39 yrs, only 4% had a partial tear
Disparity between structure and symptoms: can be applied elsewheDisparity between structure and symptoms: can be applied elsewherere
-
7/31/2019 Process Approach Oslo 12 Notes
17/69
Why not mechanical?
-
7/31/2019 Process Approach Oslo 12 Notes
18/69
Biological dimension
1. Genetic factors
2. Capable of repair and adaptation
3. Contains reserves
4. Non-linear behaviour (systems)
5. We dont know
-
7/31/2019 Process Approach Oslo 12 Notes
19/69
Why spinal degeneration?Why spinal degeneration?
Progression of degenerative signs:
Genetic and shared environmental influences47% to 66%
Resistance training and occupational physical loadingtogether
2% to 10%
N=116 twins. Study over 5yrs.
Videman TDeterminants of the progression in lumbar degeneration: a 5-year follow-up study of adult male
monozygotic twins. Spine. 2006 Mar 15;31(6):671-8Batti MC 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A studyrelating lifetime exposures and magnetic resonance imaging findings in identical twins. Spine. 1995 Dec
-
-
7/31/2019 Process Approach Oslo 12 Notes
20/69
1) MacGregor AJ, et al 2004 Structural, psychological, and genetic influences on low back and neck pain: a study of adult female twins. ArthritisRheum. Apr 15;51(2):160-72) Battie MC et al 2007 Heritability of low back pain and the role of disc degeneration. Pain 131:272280Valdes AM, et al 2005 Radiographic progression of lumbar spine disc degeneration is influenced by variation at inflammatory genes: a candidate SNPassociation study in the Chingford cohort. Spine;30:244551
Holliday KL, McBeth J. 2011 Recent advances in the understanding of genetic susceptibility to chronic pain and somatic symptoms. Curr RheumatolRep. Dec;13(6):521-7.
Heritability for LBP 52-68%1 / 30% to46%2
Neck pain 35-58%.
Why pain?
-
7/31/2019 Process Approach Oslo 12 Notes
21/69
Mechanical systems in overloadingMechanical systems in overloading
Ran
ge
Ran
ge
ToleranceTolerance
DamageDamage
Progressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failure
ToleranceTolerance
Lederman E 2010 Fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by LBP. CPDO online journal
Lederman E. 2011 The fall of the postural-structural-biomechanical model in manual andphysical therapies: exemplified by lower back pain. J Bodyw Mov Ther. Apr;15(2):131-8.
-
7/31/2019 Process Approach Oslo 12 Notes
22/69
PhysiologicalPhysiological
rangerange
End rangeEnd range
End rangeEnd range
PotentialPotential
adaptive rangeadaptive range
PotentialPotential
adaptive rangeadaptive range
Biological systems in overloading: acute optionBiological systems in overloading: acute option -- repairrepair
InjuryInjuryInjuryInjuryInjuryInjuryInjuryInjury
RepairRepairRepairRepairRepairRepairRepairRepair
Lederman E 2010 Fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by LBP. CPDO online journalLederman E. 2011 The fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. Apr;15(2):131-8.
-
7/31/2019 Process Approach Oslo 12 Notes
23/69
Biological systems in overloading: chronic option - adaptation
PhysiologicalPhysiological
rangerange
End rangeEnd range
End rangeEnd range
PotentialPotential
adaptive rangeadaptive range
PotentialPotentialadaptive rangeadaptive range
OverloadingOverloadingOverloadingOverloadingOverloadingOverloadingOverloadingOverloading
Remodelled endRemodelled end
rangerange
AdaptationAdaptationAdaptationAdaptationAdaptationAdaptationAdaptationAdaptation
Lederman E 2010 Fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by LBP. CPDO online journalLederman E. 2011 The fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. Apr;15(2):131-8.
-
7/31/2019 Process Approach Oslo 12 Notes
24/69
No progressive failure
Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. 2009 Pain in the lumbar, thoracic or cervical
regions: do age and gender matter? A population-based study of34,902 Danish twins 20-71 years ofage. BMC Musculoskelet Disord. Apr 20;10:39.
Frequency of back and neck pain same atall ages (20-71yrs)Duration slightly longer in older age
-
7/31/2019 Process Approach Oslo 12 Notes
25/69
Supraspinatous calcification: cure or calm?
Left
Right
A scan of my uncured but calmed supraspinatous calcification
-
7/31/2019 Process Approach Oslo 12 Notes
26/69
Recovery depends on cure or/and calmRecovery depends on cure or/and calm
CureCalm
or/and
Repair Adaptation Homeostasis(e.g. Short term pain alleviation)
-
7/31/2019 Process Approach Oslo 12 Notes
27/69
No evidence to suggest that we
should treat humans like a structure
out of alignment
-
7/31/2019 Process Approach Oslo 12 Notes
28/69
What is the use of a profound knowledge of
anatomy? Does it help the treatment?
What is the purpose of a standing examination?
Is palpation useful to explain a condition?
What are the aims of manual techniques or
exercise?
ClinicallyClinically
-
7/31/2019 Process Approach Oslo 12 Notes
29/69
Process Approach
An alternative
model
-
7/31/2019 Process Approach Oslo 12 Notes
30/69
Process Approach
Co-create with the patient environments in which their
recovery can be optimised.
Identify the processes that underlie the patients
condition and match the intervention according to these
needs
C l d ti t
-
7/31/2019 Process Approach Oslo 12 Notes
31/69
Complex adaptive systemsThe number of elements is sufficiently large that conventional descriptions cease toassist in understanding the system
The elements interact dynamically. Interactions can be physical or involve theexchange of information.
Interactions are multi-directional.Any element in the system is affected by andaffects several other systems.
The interactions are non-linear - small causes can have large results.
Any interaction can feed back onto itselfdirectly or after a number of interveningstages, such feedback can vary in quality.
Systems are open - may be difficult or impossible to define system boundaries
Operate far from equilibrium conditions
All complex systems have a history, they evolve and their past is co-responsible fortheir present behaviour
Some elements in the system are autonomous responding only to what is available
to it locally
CLBP as a processCLBP as a process
-
7/31/2019 Process Approach Oslo 12 Notes
32/69
CLBP as a processCLBP as a process
Too much to considerComplexity
Worse, better, chronic, recurrent etcSeveral possible outcomes
Is the pain new injury or sensitisation / inability to identify tissuecausing symptoms
Uncertainty
Condition is still there even during pain-free periodOutcome is only a particular point
within a continuum
Motor and behavioural responses associated with pain experienceInter-related processes
Sensitization + protective motor reorganizationMultiple systems, sub-events,
processes
Repair in local dimension, muscular reorganisation in neurologicaldimension as well as psychological distress
Occur in different dimensions
Pain associated with repair in acute changes to sensitization in chronicUnderlying mechanisms changeover time
Turning in bed is painful, but playing squash is OKNon-linear relationship between
input-output
Pain is not an indication of damageComplex relationships between
processes
Undefined time scale, can be recurrent, various duration. Switch on-offwithout obvious cause
Contains a time dimension
Management and recovery: multidimensionalManagement and recovery: multidimensional
-
7/31/2019 Process Approach Oslo 12 Notes
33/69
Management and recovery: multidimensionalManagement and recovery: multidimensional
processesprocesses
Repair
Fluid flow
Length adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
-
7/31/2019 Process Approach Oslo 12 Notes
34/69
Repairor / and
Adaptation
Long term change in any process depends on..
Intrinsic processes
Time dependent
Environment dependent
-
7/31/2019 Process Approach Oslo 12 Notes
35/69
LBP: a multidimensional condition in many dimensionsLBP: a multidimensional condition in many dimensions
PROCESSES
Psychological
Neural
Physical /
Local
tissue
DIMENSION CLBP
??? Not associated with tissue damage
(except in acute)
Repair??
More likely in acute LBPFluid flow
Tissue shortening or ROM sensitization?Adaptation
Persistent sensitizationNociceptive
Motor reorganisation
Loss of movement variability
Neuromuscular
Higher centre mediated sensitization
Reduced pain tolerance
Psycho-physiological
Pain / suffering
Fear avoidance
Catastrophizing
Psychological distress: depression,
anger, anxiety, hopelessness
Psychological/cognitive/
behavioural
-
7/31/2019 Process Approach Oslo 12 Notes
36/69
To be as they were before: full functionality
What the patient wants
Pain and ROM
P i ll i ti i ltiP i ll i ti i lti di i ldi i l
-
7/31/2019 Process Approach Oslo 12 Notes
37/69
Pain alleviation is multiPain alleviation is multi--dimensionaldimensional
Assist tissue repair
Normalisation of motor
control
PROCESSES
Nociceptive inhibition
Reduce fear avoidance
and catastrophizingPsychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Active movement (task specific /functional)
Dynamic movement (passive oractive)
Dynamic movement (passive oractive)
Support / reassurance / empathy Raise pain toleranceReduce sensitization
Managing pain: Treatment strategies / processesManaging pain: Treatment strategies / processes
-
7/31/2019 Process Approach Oslo 12 Notes
38/69
condition time-line
Support repair
Acute Subchronic Chronic
Tissue dimension
Neurological dimensionManaging pain: Treatment strategies / processesManaging pain: Treatment strategies / processes
change over timechange over time
RepairAdaptation
Pain alleviation and desensitization
Obscure protective roleApparent protective role
ROM Recovery is also multiROM Recovery is also multi dimensionaldimensional
-
7/31/2019 Process Approach Oslo 12 Notes
39/69
ROM Recovery is also multiROM Recovery is also multi--dimensionaldimensional
Length adaptation
Recover control of
active ROM
PROCESSES
Promote ROM
desensitization
Reduce fear avoidance
Reduce catastrophizing
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Task specific, working with taskparameters
Passive or active stretchingapproaches? (may not be effective!)
External focus of attention,dynamic, active movement
Cognitive and behavioural
reassurance
Managing ROM: Treatment strategies / processesManaging ROM: Treatment strategies / processesPsychological dimension
-
7/31/2019 Process Approach Oslo 12 Notes
40/69
condition time-line
Support repair
Acute Subchronic Chronic
Tissue dimension
Neurological dimensionManaging ROM: Treatment strategies / processesManaging ROM: Treatment strategies / processes
change over timechange over time
RepairAdaptation
ROM loss obscure protective roleROM loss apparent protective role
ROM desensitization
Alleviate fear of movement
Risk factors for CLBPRisk factors for CLBP
-
7/31/2019 Process Approach Oslo 12 Notes
41/69
Higher disability levels
Psychological distress
More social dysfunction
More social isolation
Receiving higher compensation
Work relations
Low job satisfaction
Low social support
Fear avoidance
Depression
Anxiety
Sexual & physical abuse
Psychological
Frequent heavy lifting (small
effect)Occupational
Initial high intensity pain
Specific LBP
Referred pain to LEX
Delay in treatment
Female > males
Previous history of LBP
Genetic factorsPhysiological-
biological
Long term sick leaveRisk factors
Nikolai Bogduk. Psychology and low back pain. IJOM 9 (2006) 49-53
Occupational and Environmental Medicine 2005;62:851-860Balagu F, et al 2012 Non-specific low back pain. Lancet. Feb 4;379(9814):482-91.
The dark LBP lottery: Uncertainty of cause
-
7/31/2019 Process Approach Oslo 12 Notes
42/69
The dark LBP lottery: Uncertainty of cause
Focusing on a single factor may be ineffective
The uncertainty of diagnosis
-
7/31/2019 Process Approach Oslo 12 Notes
43/69
y g
FacetFacet
DiscDisc
MuscleMuscle
1. Many spinal tissues sharethe same symptomatology
2. Sensitization spreads(Undamaged tissues willbecome sensitive to
mechanical loading)
3. Physical examinationis not tissue specific(Individual loading oftissue is highly unlikely)
Embracing uncertainty: presentation lead management (rather thanEmbracing uncertainty: presentation lead management (rather than tissuetissue
-
7/31/2019 Process Approach Oslo 12 Notes
44/69
LBP + LEXLBPChronicOver 8 wks
LBP + LEXLBPAcuteUp to 8 wks
diagnosis)diagnosis)
-
7/31/2019 Process Approach Oslo 12 Notes
45/69
Intervention as a processes
Intervention: environment reconstruction for changeIntervention: environment reconstruction for change
-
7/31/2019 Process Approach Oslo 12 Notes
46/69
Intervention: environment reconstruction for changeIntervention: environment reconstruction for change
Repair
Fluid flow
Adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
Recovery in the tissue dimensionRecovery in the tissue dimension
-
7/31/2019 Process Approach Oslo 12 Notes
47/69
yy
Repair
Fluid flow
Adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
MechanotransductionMechanotransduction
-
7/31/2019 Process Approach Oslo 12 Notes
48/69
Fibroblast
Myocyte
Change in physical environment
MechanotransductionMechanotransduction
Trans-synovial pump
-
7/31/2019 Process Approach Oslo 12 Notes
49/69
Trans synovial pump
Alteration in intra-
articular pressure
Increased blood flow
around the joint
Increase lymphatic flow &
drainage around the joint
Fluid flow
Movement
Matching techniques to physiology of repair
-
7/31/2019 Process Approach Oslo 12 Notes
50/69
High(in functional rehabilitation)
HighHighHighLow stress
activemovement
LowLowLowLowCranial
LowLowLow to mediumLowTraction
Low
Low
Low
Low
Medium to high
Medium to high
Perfect
Resemblance to
real movementHighHighHighHuman
movement
HighHighHighArticulation
low
Low
Low to medium
High (if in compression)
High
Adequate stress RepetitiveDynamicTechnique
HighHighHarmonic
HighHighMassage ST
LowLowHVT
LowLowFunctional
LowLowStretch
Recovery in the neurological dimensionRecovery in the neurological dimension
-
7/31/2019 Process Approach Oslo 12 Notes
51/69
Repair
Fluid flow
Adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
A functional approach to functionality
-
7/31/2019 Process Approach Oslo 12 Notes
52/69
Functional movement - the unique movement repertoire of an individual.
Functional rehabilitation - the process of helping a person recover their
movement capacity by using their own movement repertoire (whenever
possible).
Extra-functional a movement pattern outside the individuals movement
repertoire
Lederman E. 2010 Neuromuscular Rehabilitation in manual andphysical therapies. Elsevier
Competition in adaptation: intervention vs. condition
-
7/31/2019 Process Approach Oslo 12 Notes
53/69
processes
PainPainPainPain
sensitizationsensitizationsensitizationsensitizationorororor
ROMROMROMROM
Treatment
Transforming habitual cognitive and behavioural patterns is essential for success
Conditions for learning, adaptation and recovery
-
7/31/2019 Process Approach Oslo 12 Notes
54/69
Repetition
Cognition
Specificity
FeedbackActive
g, p y
Functional approach
-
7/31/2019 Process Approach Oslo 12 Notes
55/69
Functional approach
Shared skillsShared skills Unique skillsUnique skills
Functional repertoireFunctional repertoire
Increase stairIncrease stair
climbingclimbing
+ 2 stairs at a+ 2 stairs at atimetime
IncreaseIncreasewalking +walking +
walking onwalking on
heels or toesheels or toesSkippingSkipping
over anover an
obstacleobstacle
TappingTapping
with heelwith heel
or toesor toes GentleGentle
running onrunning ontreadmilltreadmill
Lederman E. 2010 Neuromuscular Rehabilitation in manual and physLederman E. 2010 Neuromuscular Rehabilitation in manual and physical therapies. Elsevierical therapies. Elsevier
Matching approach to motor control recovery
-
7/31/2019 Process Approach Oslo 12 Notes
56/69
YesHighHighHighHighFunctional
rehabilitation
noLowLowLow -HighLowMET
noLowLownoLowHVT
LowLowHighHighHighCore stability
noLowLownoLowTraction
no
low
no
no
no
Perfect
Similarity
To realmovement
Low
Low
Low
Low
Low
High
Repetition
LownoLowStretch
no
no
no
no
High
Active FeedbackCognitionTechnique
HighHighHuman
movement
LowLowMassage ST
LowLowArticulation
LowLowFunctional
LowLowCranial
Recovery in the psychological dimensionRecovery in the psychological dimension
-
7/31/2019 Process Approach Oslo 12 Notes
57/69
Repair
Fluid flow
Adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
Aims in the psychological dimension
-
7/31/2019 Process Approach Oslo 12 Notes
58/69
p y g
To explore and understand theTo explore and understand the
psychological processes that can assist orpsychological processes that can assist or
impede recoveryimpede recovery
Therapeutic encounter
-
7/31/2019 Process Approach Oslo 12 Notes
59/69
e apeut c e cou te
TreatmentBackgroundBackground
HistoryHistory
BeliefsBeliefs
AttitudesAttitudes
Etc.Etc.
Background
History
Beliefs
Attitudes
Etc.Practitioner Patient
Relationship
Physical/contractual
boundaries
Fox S 2008 Relating to clients. Jessica Kingsley Publishing. London
W ki ith iti d b h i
-
7/31/2019 Process Approach Oslo 12 Notes
60/69
Working with cognition and behaviour
CognitionsFearAnxiety
catastrophising
BehaviourWithdrawal from activities
Activity cycling
Illness behaviourBehavioural spheres
Therapeutic focus
Therapeutic focus
Contextual affects / factors
-
7/31/2019 Process Approach Oslo 12 Notes
61/69
Contextual affects / factors
Treatment outcomes are highlydependent on contextual affects
-
7/31/2019 Process Approach Oslo 12 Notes
62/69
The closer you look theless youll see..
Behavioural spheres and LBP management
-
7/31/2019 Process Approach Oslo 12 Notes
63/69
TaskTask--behaviourbehaviour
PsychosocialPsychosocial--behaviourbehaviour
OrganisationalOrganisational--behaviourbehaviour
Lederman E. 2010 Neuromuscular Rehabilitation in manual andphysical therapies. Elsevier
-
7/31/2019 Process Approach Oslo 12 Notes
64/69
Treatment as
optimisation
-
7/31/2019 Process Approach Oslo 12 Notes
65/69
TreatmentTreatment
Daily activityDaily activity
General / specific exerciseGeneral / specific exercise
Injury / illnessInjury / illness
BehaviourBehaviour
Patie
ntdep
enda
nt
Therapistd
epend
ant
Success of treatment rely on:
-
7/31/2019 Process Approach Oslo 12 Notes
66/69
y
Patients repair and adaptation status The ability of therapist to identify the underlying
process
The ability to match the ideal management / care/treatment to facilitate a change in these processes
The down sideThe down side..
-
7/31/2019 Process Approach Oslo 12 Notes
67/69
A process approach ultimately relays on research to inform
us about the condition and underlying processes:
1. May be wrong.. (e.g. the core model loss of core
stability = back pain
2. May be insufficient research or knowledge (e.g. whysome individuals can have profound musculoskeletal
damage but no pain, and why others become
symptomatic
3. Research is about the average, individuals are individual
Differences between structural and process approaches
Process modelStructural-orthopaedic model
-
7/31/2019 Process Approach Oslo 12 Notes
68/69
Accepts variability and individualityAccurate / precise
Processes ruleAnatomy rules
Towards co-created managementTherapist dominates the treatment
Uncertainty is OKCertainty
Condition is understood through its underlying processesCondition is understood by structural factors
Based on bio-psycho-social sciencesBased on biomechanical models (many now obsolete)
Diagnosis embraces uncertainty and is informed by processesDiagnosis is dominated by structural examinations andconsiderations
Broad multidimensional assessment (difficult to define)Examination is mostly structural
Patient needs / processes dictate managementTechnique led often a series of manual events
Condition occurs in many dimensionsOften in single biomechanical dimension
Treatment aims to facilitate processes associated with
recovery, such as repair / adaptation
Create an environment for change
Treatment aim to correct, improve or enhance physical
structure
(many techniques have no effect on what they try to achieve)
Techniques dont exist. Manual / physical events are seen as
a vehicle to deliver signals / stimulation for change
Part of the co-created environment
Techniques are seen as mechanical forces that can alter and
correct structure
Open, creative and continuously changing according to needsProtocol based
Find out more:
-
7/31/2019 Process Approach Oslo 12 Notes
69/69
Books:The science and practice of manual therapy.Neuromuscular rehabilitation in manual and physical therapies
Workshops:
See: www.cpdo.netContact: [email protected]