(BQ) Part 1 book Orthopaedic manual therapy diagnosis has contents: Introductionto spinal anatomy, introduction to applied biomechanics, function and dysfunction of the spine, neurological and neurovascular examination,... and pther contents.
Orthopaedic Manual Therapy Diagnosis SPINE AND TEMPOROMANDIBULAR JOINTS Aad van der EI, BPE, BSc PT, Dip MT, Dip Acupuncture First English Edition JONES AND BARTLETT PUBLISHERS Sudbury, Massachusetts BOSTON TORONTO LONDON SINGAPORE World Headquarters Jones and Bartlett Publishers Jones and Bartlett Publishers Canada 40 TaB Pine Drive 6339 Ormindale Way Barb House, Barb Mews Mississauga, Ontario L5V IJ2 London W 7PA Canada United Kingdom , IvrA Ol776 978-443-5000 Jones and Bartlett Publishers International www.jbpub.com Jones and Bartlett's books and products are available through most bookstores and online booksellers, To contact lones and Bartlett Publishers directly, call [ax 978-443-8000, or visit our website at www.jbpub.com Copyright © 2010 by Jones and Bartlett Publishers, LLC may be All rights reserved, No part of the material orc)tecteCl or mechanical, or utilized in any form, electronic any information storage and retrieval system, without written per- recording, or mission from the editor, and The have made every effort to provide accurate information, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use described, Treatments and side and of the described in this book may not be applicable to all peo- a dose or experience a side effect that is not described herein Drue.s and medical de- likewise, some people may vices are discussed that may have limited availability controlled research or clinical triaL clinical this field W hen consideration is being the Food and Drug Administration and to use of any often change the sponsible for determining FDA status of the drug, reading the package most recommendations on standard in the health care provider or reader is re- in the clinical and reviewing prescribing information for the and precautions, and the appropriate usage for the product ThiS is especially imoortant in the case of drugs that are new or seldom used, Production Credits Publisher: David Cella Production Director: Cover Rose Kristin E Parker Cover Image: © Sebastian KaulitzkilDreamstime,com Associate Editor: Maro Gartside Composition: Atlis GraphiCS Senior Production Editor Renee Sekerak Illustrations: PF de Production Assistant: Jill Morton j,A,M Senior Marketing Manager: Barb Bartoszek L/VU\ t' 'C.-,L , The Netherlands Manufacturing and Inventory Control Supervisor: and Binding: Courier Westford Bacus Courier Westford Library of Congress Cataloging-in-Publication Data Aad van der, wervelkolom, Englishl >rttJloD;aedlC manual therapy Joints I by Aad van der El Spine and p, ;cm, Includes bibliographical references and index ISBN-l3: 978-0-7637-5594-2 ISBN-lO: 0-7637-5594-X 1, Orthopaedics-Diagnosis, Manipulation (Therapeutics) [DNLM: Musculoskeletal Physical Examination-methods L Title Manipulation, WE 141 E37m 20lOa] RD734.E413 2010 616,7'075 dcn 2008047474 6048 Printed in the United States of America 13 12 11 10 09 10 Jones and Bartlett's Contemporary Issues in Physical Therapy and Rehabilitation Medicine Series Series Editor Peter A Huijbregts, PT, MSc, MHSc, DPT, OCS, MTC, FAAOMPT, FCAMT Other books in the series: Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management Cesar Fernandez-de-las-Penas, PT , DO, PhD Lars Arendt-Nielsen, DMSci, PhD Robert D Gerwin, MD Wellness and Physical T herapy Sharon Fair, PT, PsyD, PhD Contents Introduction ix Acknowledgtnents xi Contributors xiii PART I Chapter INTRODUCTION Introduction to Spinal Anatomy Morphology Joints Between Individual Vertebrae Intervertebral Joint Uncovertebral Joint Joints Between the Occiput, Atlas, and Axis 12 12 14 16 Spinal Musculature Chapter 23 Introduction to Applied Biomechanics 27 Statics 29 Kinematics 36 Kinetics 40 Aspects of Syndesmology 40 Chapter CostovertebralJoints and Costosternal Connections Pelvis Function and Dysfunction of the Spine 47 Static Function 47 Kinematic Function 50 Balance Function 54 Protective Function 54 Dysfunction Functional Aspects of the Connective Tissues John M Bas v 54 54 vi Contents 70 The Intervertebral Disk Rob Lanf!hout and Roel Wingbermuhle 78 of the Spinal Musculature and T heories Chapter Diagnosis 79 79 84 Movement 84 Intervertebral Foramen 85 85 85 85 Block Vertebra 85 85 (Functional Block Immobile Intervertebral Fixation 89 90 90 Scale 91 91 92 92 Biomechanical Lesion 92 93 Pain 93 93 Hyperalgesia Referred Pain Disorders in the Relationship Between Load and Luau-m:al Capacity 93 94 Release Phenomenon 94 Painful Arc 95 95 96 97 98 and M()roI1010f!1C tl:>lCl"U managed and Dassed on, The local disturbance to van Wijk the organism there are indications of through three (Li and stress, both systems show in re sponse pattern that is speCific to the (sub)system The indi 1980) vldual nature of the response • The system and the according to a more or less individual response patterns at cell level, Other writers ar gue that cellular Vl)',"W.c" alarm in which the stress process is be associated with the function of the subsystem within the greater system initiated • phase, in which the cell becomes less The sensitive to the stressor • The exhaustion stress in whIch the Psy chological of Stress leads to cell death model, stress can be re re of gradients may come about mal normal very slowly, an ulallgt: are small or arrangement of cellular reactions Every cell is capable of reacting in its 0\"'11 or lesser measure to changes, us- result in over and load may be related to Stress can arise as a result of a perceived imbalance be external demands and gradient will react directly or to the same extent If the is in tions between the individual and his or her environment, may constitute a threat to which no ad marked, more cells will react If there is a change in circumstances that affects all the cells in a justment is population, some will have a better chance pathologic survival than others wilL This depends on which reactions the cell is ca of making based on its mternal arrangement Cells are ment each other and can meet a range within individual cells but also among themselves If bal a ance is not restored milieu and every type cell that interacts with it This is also true of the dendrites of the sensory nerve cells in the with their environment When are not in a state of balance with they register the loss 0f homeostasis, on the other circumstances are of great im- is able to adapt to So as the situations that arise fall within the individual's adaptive mally If, all processes continue nor or lower concentrations at substance that in times, there an alarm is not that tion, the neuroendocrine system pathologic the biological to the situa into action and at can organisms have a greater to the there are many substances that occur the environment often presents obstacles, The ways in which the individual this affects the connective tissue, which interact and the environment On the strives to maintain lts freedom, , and not only reacts to this with a During nonnal functioning, a state of continuous tension the demands are capable of developing a new state of The mechanism exists between the but their structures differ They one overload that threatens The situations that range of molecular reaction caDabilities This means that when a their UIUlUI:>'''cU but the for tension with the environment are also more the defense mechanisms are more extensive Humans develop of behavior to meet important factors are balance and organization, A cell as a circumstances, Situations have an affective coloring: living unit are named and recognized in terms of emotions characterized a degree Stress 219 fear, anxiety, anger, and pain The need to avoid such emo Arousal only takes place after the situation has been evalu tions can result in a behavioral response The body re ated, by comparing it with previous experiences Arousal sponds to danger with activation of the sympathetic system, can also be weaker, or absent, if memory (stored or recalled) including the adrenal cortex; this reflex reaction mobilizes indicates that adaptation to the situation is a possibility The defensive resources to deal with emergencies (Cannon, situation then corresponds to an expected pattern The stored patterns of expectation are important because 1935) As in the biological model, a stressful stimulus acti vates both neurologic and endocrinological components, they enable the individual to anticipate what might happen which then interact The initial alarm phase is marked by Depending on expectation, anticipation can have an emo activation of the sympathetiC nervous system, including the tional component When the organism recognizes the stim adrenal cortex The activation of the sympathetic nervous uli system is prompt, and it has immediate effects such as suppressed: the arousal system is not activated uncondi tachycardia, piloerection, pallor, and so forth, followed by tionally by all sensory stimuli (Figure 8-4) rapid metabolic changes such as the breakdown of glycogen stimuli themselves, but the individual perception of them and fats (Smelik, 1982) The body is brought into a state of that determines whether arousal takes place This consti readiness for fight or flight tutes a filter system, which is difficult to locate anatomically, In the second phase, the system based on the frontal, and evaluates them as nonthreatening, arousal is It is not the but it is clear that the limbic system is implicated lobe of the pituitary and the adrenal cortex is activated In The limbic system consists of a number of structures lo a sense, this can be seen as counteracting the original cated inside the cerebral cortex and in the front part of the stress brain stem (Voorhoeve, 1978) The emotions and affective reaction The coordination of the sympathetic adrenomedullary system, which reacts first, and the pituitary processes have their substrate here It may be assumed that adrenocortical system, which reacts second, takes place in the emotional component of a situation is taken into ac the hypothalamus, from which both systems are regulated count in these structures during the evaluation process The The affective behavior patterns linked with the neuroen limbic structures that are involved in feelings such as plea docrine response are also anchored in the neural substrate sure and displeasure have been charted during experiments The stress based on (self-)stimulation The following systems were of the hypothalamic circuits (Smelik, 1982) inducing stimuli are processed and the neuroendocrinological identified: and behavioral outputs are produced via the hy pothalamus Previously, the physical and chemical factors that con • tribute to stress input were described The emotions also of pleasure) play an important part It is the psychological component rather than the somatic stress-inducing stimuli that seems • also by the anticipation of threat implied by the stimulus The sy stem that leads to avoidance behavior (feelings of displeasure) to be responsible for powerful stress reactions The adrenal system is activated not only by the damaging stimulus, but The system that leads to approach behavior (feelings • The system that leads to a powerful self-defense reac tion (fight-night, anger-fear) The individuals evaluation of the threat plays a key role From a psychological point of view, experiencing and as Uncertainty and the absence of clear expectations play a sessing the situation are important in relation to stress part in activating the last of these systems It involves a inducing stimuli strong neuroendocrine reaction Psychologists refer to levels of alertness as arousal A state The arousal system (ARAS) and the evaluation system of heightened arousal is associated with raised cortisol levels, (limbic system) appear to be closely linked Both can be which indicates that the organism is under attack Aspecific seen as parts of a larger system (Smelik, 1982) The results arousal comes about through the reticular formation in the of the processing of stimuli by these two systems are inte brain stem, where the ascending reticular activating system grated at the level of the hypothalamus, which is the source (ARAS) is located (Smelik , 1982) This system receives ex of the Signal for the integrated behavioral and neuroen tensive collateral input from sensory systems and fans out in docrine reaction a diffuse manner to the cerebral cortex If this system fails, Fear plays an important part in the avoidance behavior the result is unconsciousness; if it stimulated, the result is a that is characterized by feelings of displeasure Repetition of state of heightened alertness Unexpected and powerful sen a threatening situation can lead to efficient adaptation in sory stimuli can cause strong arousal, together with the asso one individual and to a self-perpetuating progressive loss of ciated neuroendocrine response adjustment in another Weiss (in Smelik, 1982) performed In many cases, sensory stimuli seem to have an activating effect only when they have a certain emotional significance experiments on rats in an attempt to identify the underlying factors 220 PSYCHOLOGICAL ASPECTS RETUCULAR MEMORY ACTIVATING EXPERIENCE SYSTEM FLEXIBLE EMOTIONAL SYSTEM (ASSESSMENT OF THREAT) (ALARM) SENSITIZATION FEAR ACCOMMODATION + -•• INADEQUATE ADEQUATE Figure 8-4 PSYCHOSOMATIC IMPA IRMENT _ •• - IMPAIRMENT AT ORGAN LEVEL Processes during stress reaction Two rats received completely identical noxious stimuli Various factors can have a positive or negative influence One rat was warned by a signal seconds before the stimu on the state of mind Negative factors such as feelings of lus was applied; the other rat received no warning After a powerlessness, being unable to anything, loneliness, and few days, the second rat had developed gastric troubles, feelings of abandonment increase the fear and tension Posi while the first rat, which received the warning, showed little tive factors that reduce fear include feelings of safety, of secu sign of disturbance Weiss concluded that it was not the rity within the group, of being able to tackle the situation, threatening stimulus in itself that caused the pathologic and of being able to act If a way cannot be found of master symptoms, but the anticipation of fear Fear and uncertainty ing the situation or adapting to it successfully, the individual about what will happen seem to intensify the stress reac is drawn into a downward spiral that can lead ultimately to tion; the neuroendocrine reaction appears to be propor breakdown The spiral effect is a result of the presence of a tional to the level of nervous tension caused by fear People constant threat against which there is no protection The sit use a number of techniques for reducing anxiety; these in uation is experienced as increasingly threatening and un clude action, verbalization, denial, and prayer pleasant, and anxiety and tension increase T he somatic When suffering from psychological stress, it is important symptoms also become more serious and intense Fear itself for the individual to find ways of reducing the levels of fear reinforces certain behaviors Psychological conditions such and despair Effective ways of protecting oneself can lead to as apathy, depression, and aggression are increasingly occur successful adaptation: accurate anticipation , for instance, ring because of "breakdown inadaptation." suppresses the physiologic stress reaction to the maximum From a diagnostic point of view, it is espeCially important extent possible If the individual is not capable of adapta to identify a parameter by means of which the level of anxiety tion and cannot find an effective way of anticipating, psy can be measured Therapeutically, a multidisciplinary ap chosomatic symptoms will occur On the other hand, as proach is needed in many cases Treatment by manual therapy feelings of self-efficacy grow, the anxiety decreases, and with of identifiable tissue-specific changes that have a psychological it the somatic reaction The most important thing is for the cause or a psycholOgical component is no more than sympto individual to feel defended and safe as an organism in rela matic treatment It is only when the factors that preCipitated tion to the environment This subjective feeling is closely the illness and those that nmv maintain it are identified that related both to personality and to experience manual therapy can play a part in the curative process Chronic Pain Syndrome 221 If a physical problem is the primary cause of the stress reaction, this should be treated in the first instance by man Pain behavior ual therapy, with psychological input in a supporting role Pain experience CHRONIC PAIN SYNDROME Studies have shown that 86% of people are troubled by low back pain at some time in their lives, 5% of them every year Of these, 19% have back pain that follows an atypical Nociception course, and they are referred to a manual therapist with chronic nonspecific low back pain The manual therapist is regarded as competent to devise a behavioral approach in addition to offering the specific manual therapy skills Pain Figure 8-5 Loeser's Egg Chronic pain syndrome is diagnosed in cases where a dysfunction accompanied by pain has lasted more than 12 weeks Nociception is the signaling process that informs the central nervous system of tissue damage or threat of damage leading to a subjective experience of pain Pain is a subjective signal that can be described as a sensory and emotional experience associated with actual or potential tis StlC damage, or that is described by the sufferer in terms of such damage Every individual learns the meaning of the word pain In "Loeser's egg" (Loeser, 1980), pain and its effects are represented as consequences of interactions among physi cal, emotional, and environmental factors (Figure 8-5) through experiences related to a mishap earlier in life Pain Nociception is neurophysiologic transmission of the dam has both an organic and psychogenic component; these age Signal to the brain Pain perception is the registration of cannot be separated or distinguished According to the gate the signal by the brain Pain experience is the meaning that theory of pain (Melzack and Wall, 1965), two different the individual attaches to the pain perception Pain behavior nerve conduction systems are involved: a pathway consist is the individual's communication about the pain \vithin his ing of thick nerve fibers with a high depolarization thresh or her environment old, and a pathway consisting of thin nerve fibers with a In patients with chronic pain, the pain experience and low depolarization threshold Activity of the thick fibers ob the pain behavior seem to be central This suggests that the structs Signal transmission to the brain (closes the gate) Ac patient himself or herself may be able to something tivity of the thin nerve fibers facilitates Signal transmission about the pain by exercising various forms of control to the brain (opens the gate) It is also known that informa tion descending from the central nervous system can open the gate by stimulating transmission, and that it can close the gate by inhibiting transmission The information thus obtained from the periphery and from higher centers deter mines whether, and to what extent, the pain signal is trans mitted to the thalamus, the limbic system, and the cerebral Classification of Dysfunctions Complaints involving persistent pain in the movement system can be grouped as follows, according to their dura tion and to the objective somatic findings: cortex Tension, grief, irritation, worrying about pain, fear, and inaccurate interpretations of the pain all seem to stimu late pain transmission; this causes the gate to open, and there is increasing pain awareness An exciting sporting • • • Acute dysfunction, to weeks Subacute dysfunction, to 12 weeks Chronic dysfunction, longer than 12 weeks event or film, enjoyable music, and movement within the limits imposed by the pain seem to have an inhibitory effect One of the most important features of the development on pain transmission; this causes the gate to close and stops of chroniCity is the atypical course of the patient'S recovery awareness of pain Recovery is considered atypical when there is no reduction 222 PSYCHOLOGICAL ASPECTS in pain, no lessening of the restrictions on movement and Profile 2b does not belong in the chronic phase but has activities, and no change in participation levels within the potential to develop into a chronic state The therapeu weeks of onset An atypical course of this kind indicates tic approach is, therefore, the same as that for profile 3b, that the disorder needs a more comprehensive approach which does form part of the chronic phase than the basic biomedical one Psychosocial factors could be inlluencing the course of recovery and must be taken into account The atypical course of recovery and/or the persistence of the complaint may be caused by any of the follOwing factors: Models of Development of Chronic Pain The follOwing three models can all contribute to an un derstanding of the etiology of the chronic pain syndrome: o • Biomedical factors such as decreases in mobility, muscle strength, stability, and coordination (decondi tioning) • Psychological factors such as fear of movement (ki nesiophobia), unrealistic thoughts about the pain, o o Social factors such as the work situation, lack of Psychosocial stress model: Here, too, the pain is attrib uted to muscular tension, \vhich is a consequence of inability to find solutions to emotional problems ing dramatization of the condition, leading to cata strophizing Reflex-spasm model: Pain is regarded as a consequence of protective muscular hypertonicity following injury lack of confidence in the help provided, and increas • Biomechanical model: The basic assumption is that faulty patterns of muscle activity can lead to pain The chronic pain syndrome provides an illustration of the multimodal nature of long-standing problems For some support anc:l/or acceptance, reinforcement by the years now, approaches to diagnosis and treatment have taken environment into account psychological as well as biomedical factors The Guidelines on Manual Therapy for Low Bach Pain is sued by the Royal Dutch Society for Physical Therapy offer the following classification of recovery profiles: Acute phase (0 to weeks) The chemical processes that take place at the supraspinal level are not yet fully understood from a biomedical point of view and are, therefore, difficult to inlluence This is probably the reason why behavioral therapists have become interested in the problem and have developed a behavioral approach consistent with the biopsychosocial view of hu • Profile la: Normal course mans (Vlaeyen, Kole-Snijders, and van Eek, 1996) This ap • Profile lb: Atypical course proach is based on the view that complex interactions Subacute phase (7 tol2 weeks) • • Profile 2a Atypical course without social factors Profile 2b: Atypical course with social factors (yellow Ilags) among biological, psychological, and social variables can cause anc:l/or maintain pain behavior The general characteristics of the chronic pain syndrome are as follows: • Chronic phase (up to12 weeks) o Profile 3a: Managing the complaint adequately nection can be found vvith active physical pathology • • Appropriate participation SpeCial features of the chronic pain syndrome are as follows: Episodes of increased pain complaints • Profile 3b: Inadequate management of the complaint Little or no self-efficacy o Reduced participation Excessive use of medications, possibly with adverse effects o Not coping adequately Load not adjusted to load-bearing capacity Disturbed psychosocial functioning (Vlaeyen et aI., 1996) pain in the terminology section later in this chapter) Load adjusted to load-bearing capacity A history of a series of unsuccessful medical inter ventions High degree of self-efficacy Coping adequately (see the definition of coping with Long-standing complaints of pain where no causal con Multiple surgical and pharmacologic treatments, with adverse effects o Increasing physical restriction because of fear of pain and injUry Chronic Pain Syndrome of and despite the new treatments • Interpersonal Fearful and more attentive to • Decrease in self-worth and self-confidence and dissatisfaction with the ConDlcts with treatments or with health care in general • • conflicts with partner Family and • members Decrease in • of partner who stresses the contact • activities to denve reinforcement from factors that may indicate increased risk of flags) are discussed in the to Negative expectations with work and/or sport activities chronicity Insufficient support in of self-worth and self-confidence socia! isolation and loss of interest in social • Conviction that work and/or sport is/are damaging • Problems in present work • lists work Previous and (Waddell and Waddell, 2000; Vlaeyen et aI., VNTPY"""nc An damage and injury affective disturbances • 223 Terminology About Pain • Back • Pain is uncontrollable is a disorder • Rest is the best the behavioral examination, it will be Before useful to define some of the terms that are used PYlrlP,'lP'1rp and stimuli The concepts of attribution and expectation are important in this context Behavior • Attribution: The search for a cause to which the pain can be Control of health is handed over to others attributed The cause is locus of control) • Use of orthoses and ambulatory • Much time devoted to bed rest; avoidance of and in terms of its relevance danger It is the search for an answer to and its The consequences of pain are often this can lead to may be underestimated or overesti activities "' fJ"'" one were stronger than one is worse since pain started and unintended maintenance of may also have • No financial motivation to resume work • Problems over pay and benefits relating to prolonged absence because of the pain LI'L'VWJ.'" • best case, the pain is less troublesome than on earlier treatments • Passive forms of treatment • Past of a series of ineffective treatments Emotions work f)prm>cci"p and more irritable than pvnp,crpr1 during certain activities, and these can then be extended This raises the Pain of able to man that he or she attributes the nrtlVP'''H-r1' Confusion about the U,,"""V;) Fearful of ten results in avoidance of a range of activities In the age the and Treatment jpn,pn.(ipr1rp • about the extent to which the pain can be controlled This of Financial Pain to his or her own efforts and behavioral ef fort that the individual expends in trying to master, re duce, and tolerate the internal and external demands and 1980) 224 PSYCHOLOGlCAL ASPuTs patient to use such as bed rest and medications The himself or herself as dependent on others and restricts activities that and course; the nags); work situation, family, and habits These are all [actors that may started , to know what sig and whv it oersists It stressful life events , unsatisfac out of work There is a high risk of confronted with that one cannot solve whether attaches to the and whether the patient there are any irrational is able to control the conmlaint and/or has a fear of movement attention should be to of the [ollowing levels of overanx effect • f'\[)sence behavior • • Unclear Excessive and • exceSSive! Reluctance to talk divided into "avoiders" of activities and "confronters" The avoiders may physical aVOldance of and complications and social ac lCCWl/)" of self-\vonh tivities; this may result in the disuse syndrome Atrophy which causes more pam of the muscles reduces it can lead, and further avoidance of self-worth and among other to deoression which in turn lowers the vain threshold • skills Lack of about the his Obtain answers to the tory of the of • for • • • • • • and the consistency • thmk lS causmg the What What What What the of How the members know when the is in • • When the What does at limited activity and par ticipalion How did What the members react to it? What are the consequences of the tient's that are explored its nature, seriousness, How the • How does the affect the for the pa Chronic Pain Syndrome • How does the • Does the • From the affect sexual behavior;> point of panded what is the aim of What would the if the were tr'lrrPTTlPlnt of pain behavior: • supplementary • Presentation at less than 20 or more than 55 years Trauma (fall or road accident) rein of carcinoma, forcement includes avoidance of events and activities mis use, or HlV Reduced participation in social and physical activities loss The leads to reduced falls into a • Persistent noted restriction of lumbar flexion abnormalities • III y/'pm, 1'''' ! behavior Others of examinations age skills and seeks social contact behavior with disorders: Serious of pain behavior The of upon carried out to rule in or rule out pathology Redj1ags or if he or she could cope with it better? are the types of the examination must be ex order is the treatment7 • intervention If a serious dis percentage need the 225 of activities • Structural deformities or II Cauda disorders: Examination Di agn ostic Subdivision of Examination • Problems with micturition • Loss of anal • Saddle that may be of • ble for low back pain: low back be related to or dysfunction, or it may across the arise spontaneously The pain often lower back and into one or both buttocks or thighs to the cause, there is little correlation be tween the anatomic localization of the clinical syndromes, and current pathology • Nerve root IJ"JWIJ:>C.\ t or Nerve root pain may be caused by a dlsk, spinal hesion Mostly it affects loss III and related • Gradual onset before age 40 • Marked stiffness in the • Persistent restriction of movement in all directions • Involvement of peripheral urethral or postoperative ad one nerve root The motor loss in the or disturbance of gait is most common between the ages of 20 and 55 It may With involvement (more than Widespread one nerve low back pain • or around anus, genitalia to Waddell and Waddell (2000), there are three distinct tone or rectal incontinence anesthesia • Positive occurs in a near-dermatomal distribution in one past the knee to the foot and toes There in may be tingling and loss of feeling in the same area the in the can result in motor, sensory, and • Serious disorder s of the column Tumors and in are present I % of cases of low rheumatic inflam The pain is caused mation caused m less than I % of cases Less than 5% are real nerve root of Is the from the back.? Is the cause of the situated in the associated with a nerve root a small or is the back Are the part of a disorder in an organ or involved? Is there a Is there a problem! spinal deformity or a widespread neu ro- disorder? Is there a of structural scolio sis or of pain devi.ation because of unilateral muscular 226 PSYCHOLOGICAL ASPECTS spasm? The latter often disappears when the patient reveal "yellow flags," a detailed examination is needed of lies down Widespread neurologic symptoms affect the several myotomes or both legs whether these could be wholly or partly responsible for the The gait may be disturbed or unstable There may be problems with urinary retention or overflow in continence In case of doubt, a more extensive neuro logiC examination should be made, consisting of the patient's • • Sensory tests of arms, trunk, and saddle area the practitioner needs to explore the follOwing questions: • causes a sharp, localized pain, which affects the asso ciated dermatomes, while somatic Is the patient coping with the complaint adequately or inadequately? • Is the patient coping by exercising personal control (internal locus of control) or exercising little or no personal control (external locus of control)7 upgoing plantar ret1exes, loss of position sense in Is a nerve root involved? Stimulation of the nerve root establish When assessing patients who are in the chronic phase, creased muscle tone, accentuated reflexes, clonus, the toes, and pOSitive result on heel-shin test to pattern of complaints If this proves to be the case, therapy Palpation of bladder Examination for upper motor neuron signs: in circumstances must be planned accordingly following: • psychosocial • • • Is the patient's way of coping adequate or inadequate? Are load and load-bearing capacity balanced, or not? Is the patient's level of participation appropriate, or is partiCipation reduced? referred pain, which seldom extends beyond the knee, causes a piercing, usually poorly localized pain Nerve root compression, linking additionally to radicular pain, often gives rise to tingling and numbness The pain in the leg is often more severe than the pain in the back Ninety-eight percent of prolapsed disks affect the L5 and S1 nerve roots Stretching the irritated root repro duces the nerve pain Pain in the leg when coughing is a positive sign For further information on nerve root problems, please see Chapter titled "Neurologi Behavioral therapy Proactive Measures Aimed at Preventing Chronicity These measures are intended for patients in the subacute pain phase whose recovery is following an abnormal course: • cal and Neurovascular Examination." • Is there serious spinal pathology? Although serious • spinal pathology is found in only % of cases, the possibility should be explored to reassure the patient There is a greater chance of spondylolisthesis in pa • • Discrepancy between reported pain and objective Painful complaints that limit the performance of de sired motor activities osteoporosis It is important to remember that non • Ability to formulate concrete, attainable goals that are consistent with the therapeutic possibilities The aim the points mentioned under I, II, and III must be of treatment is not to reduce pain, but to improve carefully considered to ensure as far as possible that functioning serious pathology has not been missed Varied data must be considered together when forming a clinical Stimulating improvement of problem-solving skills medical findings age of 55, there is a greater chance of metastases or mechanical back pain is independent of posture All Graduated increase in level of activity Inclusion Criteria tients younger than the age of 20 years In patients presenting with a first episode of back pain after the Information and gUidance • The patient's partner is ready and able to take part in the partner course opinion Exclusion Criteria Behavioral Examination (Yellow Flags) In cases of idiopathic disturbance without a clear cause, that is, where the phYSiologic substrate is unknown, the de • • • chosocial history and the biomedical examination If these Other problems that affect the pain and that cannot be treated or alleviated by supportive care cision whether to adopt a biomedical and/or a behavioral treatment approach is made on the basis of the biopsy Serious psychopathology such as psychOSiS, SOCiopathy Addiction problems, such as alcohol or drugs • An ongoing legal dispute about the payment or reten tion of benefits Chronic Pain Syndrome Arguments in favor of the behavioral approach include the following (V laeyen et aI, o There are three types of behavioral treatment: 1996): Pain has at least three forms of expression: stress, pain cognition, and pain behavior o 227 The presence of underlying physical pathology does o Operant approach o Respondent or relaxation approach o Cognitive approach not mean that cognitive and environmental factors have no inOuence on the pain o The factors that maintain the pain are not necessarily the same as the factors that caused it to develop in the first place o The extent to which patients are limited by pain is the product of interactions among physical, cognitive, emotional, and environmental factors Operant Treatment The aim of this treatment is to raise activity levels and decrease the pain The first step is to establish the baseline for the exercise programmed The patient is asked to per form a particular activity, for example, cycling on a home trainer, until the pain can no longer be tolerated Using this as a baseline, the starting level is set just below it Therapist and patient then agree on a short-term attainable goal The Information and Advice It is important initially to convince the patient that his or her behavior inOuences the pain and that he or she can have some control over recovery and on whether the com plaint recurs or spreads Factors that are important in this context include the patient's attitude: how the patient sees the behavioral changes in terms of social infl uence; how oth ers regard the behavioral changes in self-efficacy; expecta tions as to whether the program wi.ll be successful The model described by van den Burgt and Verhulst (2003) consists of a series of steps called "being open," "un derstanding," "wanting to do," "being able to do," "doing," and "continuing to do." The patient is given infonnation about the nature and course of the complaint, the relationship patient reaches the goal in a series of time-contingent steps (graded activity) The therapist and patient then negotiate and sign a treat ment contract; this contains a treatment plan in which every stage is specified in tenns of a starting level, a series of steps of increasing difficulty, and an end goal The patient should no more and no less than is stated for each activ ity in the contract The long-term goals are set in terms of meaningful uses of time, such as hobbies, work, sport, and family activities Positive reinforcement is vital when the pa tient succeeds in mastering steps in the plan When phobias are involved, exposure techniques are an option For fuller information on the aims of operant treat ment, please see Psychology of Unexplained Chronic Pain by Passchier et al (1998) between load and load-bearing capacity, and the importance of an active lifestyle It is important to explain to the patient that pain is not necessarily associated wi.th tissue damage Attainable goals must be agreed upon in discussion with the patient, and the patient must be prepared to maintain the agreed-upon behavior All information must be given in a language that the patient understands and in an atmo sphere of trust to optimize the chances that the patient wi.ll use the information and put the advice into practice Respondent or Relaxation Treatment The first requirement is that the patient must be able to recognize stress The methods used to achieve this include progressive relaxation, autogenic training, transcendental meditation, and yoga The most suitable method next to op erant treatment is relaxation through muscular activity Oa cobson method) This is a concrete, graded approach that places no demands on imagination Behavioral Principles In practice, the method is to contract a particular muscle or muscle group, and then relax it The patient then prac Behavior therapy is appropriate in cases where it seems tices relaxing the muscles without contracting them before clear that the pain and restricted movement are a result not hand The next stages are cue-controlled relaxation, where, only of somatic factors, but also of possible psychological fac using abdominal breathing, the patient counts to tors and the sickness behavior of the patient When planning breathing in and to therapy in such cases , and treating joint dysfunction, the cli ation, where only those muscles are contracted that are while while breathing out; differential relax nician emphaSizes the use of behavioral principles The aim needed for a particular activity, while the rest remain re of behavioral therapy in these circumstances is to change the laxed; accelerated relaxation, where the patient relaxes for patient's behavior in relation to movement functions 20 to 30 seconds, preceded by abdominal breathing This 228 PSYCHOLOGICAL ASPECTS should be • introduce exercise, in which the lim The final stage but the ing relaxation in stressful situations or in moments of seri ous of time dur ing which the patient will exercise • Positive reinforcement of of the exercises Cognitive Treatment • about his or her own The locus of intervention can be either et ai, behavior pain attribu The purpose of this treatment is to tions and the Extinction of the or stress The treatment can be combined de sired with relaxation exercises, The Therapeutic Process In discussion with the functions and/or activities from a baseline chosen that can be built up step The program consists of three phases: The activi exercise The should be those that are most ties to be to the patient The baseline is chosen so as to allow the pa tient to carry out the chosen activlties as without and as well as the theraDist and the of treatment, duration, as an """Pl'l"'1(,1> is one's emotions and by can be modified control oneself The needs to become can something about the convinced that he or and can exercise controL • The functional and behavioral result • The and of motor and skills • then used to try to alter its most activities and The time scale for The creation of a realistic exercises in thelr in which then in actual life, Exercises are also and to the tissues these can be checked to see what progress made to is not synonymous with past The time-dependent activities may not exceed the paand neither may When we consider the three kinds of treatment, it is combines best with the clear that the operant kinds of activities involved in manual The goals of the operant approach are as follows: of the task If progrcss, the influence at home does not of the directed sessions must be increased If the results of the home exercise program are the sessions can be increased The ultimate aim is • and Increase to the the should take for con- the exercise program: this is the final step, • Promote ways of the symptoms The following measurin2: instruments can be used: UI t:LlJ!."gt: avoidance behavior • Raise • Improve the relevant functions Risk Factors levels build up a program of exercises Linton and Complaints This identifies three to five 229 Chronic Pain activities and the each rated on • to which are of the TSK Test-retest 0-10 scale r = 0.78 Visual The as a scale various clinical ical variable in rules relevant to OMT clin has been discussed earlier (in Swinkels-Meewisse et al a Crohn from 0.70-0.72 for the internal back alpha Activity subscale of the of the from 0.82-0.83 for the Work sub subscale as indicative of poor outcome This scale charts restrictions and particiIt lists 20 activities, which are sation very llt Low concurrent rho extreme be useful to use ment of in pa workers' compen tients with low back with the TSK 33-059) indicates that it the FABQ and the TSK in assess WIth low back Meewlsse et aI., 2003) ThIS list tests and measures is help the serious researcher to locate the literature In which the instruments are described and their cussed The clinician should have a available how to • Pain control question list purpose of this list of The to detennine whether the locus of control is internal or external Scale for The scale measures mmt Swinkels-Meewisse Crohnback et aI., fear of move a (2003) 0.70-0.76 for the in- extent methods This tlent has a right and the most effective treatment dis of ... Describing the Examination Chapter 11 3 JLU"''-;;Y Introduction to Test Psychometric D n ti 11 5 Peter A Huijbregts 11 5 11 5 Standardization 11 8 12 1 12 2 Confidence Intervals PART II Chapter and Examination:... Manipulation, WE 14 1 E37m 20lOa] RD734.E 413 2 010 616 ,7'075 dcn 2008047474 6048 Printed in the United States of America 13 12 11 10 09 10 Jones and Bartlett's Contemporary Issues in Physical Therapy and... 14 9 15 6 18 0 18 6 18 6 18 6 Static and Dynamic Coordination 18 7 Nystagmus 19 7 Motor