Figure 1: A model of everything : the neuromatrix is used
as a model (cognitive process oriented structure) to describe the various
input which the therapist can offer to 'enable' the client to engage in
their path to recovery. Hereby, an evidence based approach using 'the
values and beliefs' of the client is integrated with the scientific evidence
base from physiotherapy, the pain sciences and psychology. Importantly,
the therapist gains confidence through their success at predictive reasoning,
whilst the client gains emotional confidence in their ability to undertake
goal-oriented activities without the fear of exacerbation or under-performance.
Heuristics versus Constructivism
 
Figure 2: A useful instructional model used to describe
a 'top-down' clinical approach with a scientific clinical evidence based
approach of biomechanics and neurophysiology.
Figure 3: Increasing the validity and reliability of the
clinical reasoning by correlating all aspects of the subjective and physical
examination into a meaningful clinical picture (pattern recognition) -
adapted from Maitland (1986, 1991).
Treatment as a product of a systematic assessment
Although an at 'out of fashion' terminology, the aggravating/easing factors
are a disability measure which can be used to assess the neurophysiological
and biomechanical state of the pathology. By analyzing the movement and
loading characteristics of the aggravating and easing factors the therapist
should gain a measurable outcome tool for assessing the efficacy of treatment.
Additionally, the information can be used to correlate it with impairment
measures of the physical examination. Improving the internal reliability
by correlating information across the entire examination process enhances
the validity of your treatment and re-examination process. Ideally, the
therapist should have at least 3 aggravating/easing factors to assess
outcome. Otherwise, a more in depth analysis of the aggravating/easing
factors should be undertaken using inductive
reasoning. For example, if the client only complains of shoulder
pain when lifting a load above their head, then clarify this statement
by asking whether it is the movement which is painful, the duration of
lifting, the manner of lifting or the size of the load which is being
lifted that is significant. Night pain, the frequency of waking and the
ability to return to sleep are also useful measurement tools. Psychometric
disability measures can also be used if they don't result in resentment
or irritation from your client.
Further aspects of the subjective examination can be used to assess the
past history as it relates to the current problem. Is it the same problem
re-aggravated or is it a new problem which is influenced by the old injury?
Assess the biomechanical aspects of the original mechanisms of injury
as well as those of re-exacerbation, as well as the frequency of exacerbation
and make a judgement as to whether the problem is getting worse, better
or staying the same. If it is getting worse, then why? Are there components
of misuse (reduced co-ordination/stability),
disuse (atrophy and reduced capacity
of loading), abuse (trauma), or overuse
(repetitive loading and microtrauma) which are contributing to the 'cause
of the cause' of the problem. A long history of problems may identify
fear-avoidance behaviour and generalised 'disuse' and/or of more specific
'disuse' of the multifidus and transverse abdominis muscles. Combine this
with 'overuse' of the erector spinae muscles leading to excessive compression
of the intervertebral disc and consequent neural irritation of the dorsal
root ganglia resulting in ectopic impulse generation and increased muscle
tone in the deep hip rotators, hip flexors, hamstring and calf muscles
which creates 'misuse' of the lower limbs ('the tail that wags the dog
phenomena') generating shearing and rotating forces across the pelvis.
Old injuries may not only reduce the biomechanical integrity of the tissue
but it may also increase the neurophysiological sensitivity of the neurones
whose nerve fibres innervate the territory of previous injury. Ascertaining
the recuperation from previous injury will provide an insight into the
clients 'active' and/or 'passive' coping strategies.
People who have had frequent passive treatment inputs and have recovered
may find it difficult to embrace a more active treatment approach. Those
who haven't recovered may be in a state of 'learned helplessness' who
will similarly require convincing to embark on a more active form of recuperation.
Importantly, the active treatment approach must embrace the impairment
and disability measures of the subjective and physical examinations, thereby
allowing the client to measure success leading to the ultimate goal of
full self management and/or complete recovery. Therefore, this process
requires an element of education whereby the therapist's
'hands-on' treatment becomes 'exercise
enabling' and/or 'performance enhancing' for the client.
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