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Instructional Design in Clinical Reasoning

Clinical Reasoning, as a means to an end, for the development of Self Actualisation as a primary care Musculoskeletal Physiotherapist

by Martin Krause (1999-2008)

The science of navigation can be taught, the art of navigation needs to be learnt through experience.

Art is about the experience of questioning conventional paradigms.

The conundrum for health professions is that 'statistically' we work within a 95% confidence interval. Hence, when working with human bodies we are invariably working on the edge of the unknown. By using a structured reasoning approach we can eliminate variables from a list of probabilities, eventually defining the essence of the clinical picture. Hereby the umbrella diagnosis which incorporates everything but means nothing (eg Non-specific low back pain) is eliminated.

These pages present a structure and a process to the art of learning clinical reasoning. It will encourage the reader to interpret all findings, be curious of why some things work and others don't, and why some things work most of the time but not all of the time. It will also endeavor to provide a navigational chart of learning whereby the clinician can excel whilst standing on the shoulders of clinical research giants.

Experts don't store answers, rather they store key facts and strategies which help them gain those answers. Hereby, they use long term memory that has taken at least 10 years of concentrated effort using metacognitive and reflective thinking strategies. Experts tend to recruit larger areas of the brain for information processing thereby increasing their RAM capacity. Neurons that fire together, wire together. This leaves the short term memory free for processing novel stimuli.

Expert opinion lies on the lowest rung of the Evidence Based Practice (EBP) hierarchy. However, the process of Practice Based Evidence (PBE) should form an integral part of every treatment strategy and hereby provide a catalyst for EBP. One form of consensus decision making is the Delphi approach whereby several experts are asked an opinion about a presentation. During a second round, the experts are shown all other opinions and then asked to rank those opinions. The objective is to use several rounds of questions and answers to narrow down the opinions to those which are most likely or more probably. The following is a summary of the processes needed clinically to develop ones clinical opinion expertise and how interaction with the client and other professions can lead to an optimised management strategy and hence treatment outcome. Hereby, Dogma is reduced and many avenues of thought are accommodated.

"fish live in the sea, therefore all things in the sea are fish"

One of the crucial ingredients of successful education is the ability to learn from mistakes. Structured clinical reasoning should limit those mistakes to within a margin of safety. Unstructured reasoning, in a wealth of information creates a poverty of attention.

"it ain't what you don't know that gets you into trouble. It's what you should know for sure that just ain't so"

(Mark Twain)

"Liberate your mind and only then will you find your freedom"

(Malcom X)

Table of Contents

- Clinical Reasoning

- Philosophy

- Scope of Practice

- Mind Maps - clinical examples

- Predictive Reasoning

- Neurolinguistic Programming

- Schroedinger's Cat

- Multimodal Treatment approach

- Learning sequence

- Vascular System

- Drug side effects on MSK system

- Treatment as a product of systematic assessment and reasoning

- Misuse, Abuse, Overuse, Disuse

- Stage, Stability, Irritability, Severity

- Cause and Affect

- The Immune System

- Allostasis

- Theoretical Clinical Explanations and References

- Clinical Reasoning Examples

- Forward Thinking

- Conclusion

- References



Clinical reasoning is the process by which the Musculoskeletal Physiotherapist assesses the client's dysfunction. Titled Australasian Musculoskeletal Physiotherapists are trained in the superior clinical reasoning skills required for independent self-directed reasoning. The cognitive and meta-cognitive skills required for clinical reasoning may lead to expertise if applied clinically for at least 10 years. This process not only allows the clinician to recognize their limitations, moreover it empowers the clinician to know how to plug any gaps in their knowledge by either researching a particular topic and/or attending post-graduate training courses (self directed learning). These skills are founded under the umbrella of life long learning (the 3 L's).


It is important for the clinician to

  • Identify and prioritise professional and personal goals they want to achieve in a set time frame.
  • Recognise the key components of effective goal setting.
  • Clearly define goals based on their organisational role.
  • Motivate themselves and their team to attain their goals.
  • Identify key obstacles to achieving individual and team goals.
  • Create action steps to accomplish individual and team goals.
  • Develop techniques to ensure follow through.

Hereby, the clinician can try to optimise the environment in which they wish to thrive.

However, Taylor (1979, 1986, 1987) described 4 phases of development which include

  • detachment
  • divergence
  • engagement
  • convergence

and associated transition points that result in

  • disconfirmation - major discrepancy between expectations and experience
  • disorientation - confusion and a crisis of confidence
  • naming the problem - without blaming self or others
  • exploration - open ended exploration with a gathering of insights, confidence and satisfaction
  • reflection
  • reorientation - a major insight with a simultaneous new approach to learning/teaching/treatment
  • sharing the discovery
  • equilibrium - new approach is elaborated, refined and applied
(Candy, PC 1991 Self Direction for Life Long Learning : Jossey Bass Publishers)

Clinical Reasoning is analogous to travelers on a highway. Some are the drivers, others are the passengers. Through experiential learning, the passengers curiosity and confidence can be aroused to become a driver. All the travelers must obey the same road rules, yet they all have a different skill set. The road rules are the consensus of professional practice, whereas the skill set reflects experiential clinical learning. The highway represents the algorithmic structure of assessment, inductive and deductive reasoning. This highway becomes a freeway once these algorithms are rehearsed and automated from frequently repeated subjective and physical examinations. Similar to highways linking towns, the examination links historic events and involvement of body structures, which have either precipitated or have become involved with the current dysfunction. Once the travelers arrive in the town, they experience a more complicated maze of streets with innumerable possibilities. Similarly, as the clinician hones-in on the precise nature of the problem, the experienced clinician uses a more nebulas reasoning process, which may resemble 'fuzzy logic' whereby they recognize clinical patterns based on their unique past experiences or they recognize a novel clinical reasoning experience, which will require inductive as well as deductive reasoning. Similarly, the travelers in the town can use more cumbersome roads to get to their destination or they may know a more optimal route based on examination of the street directory, previous learning, as well as asking local people for advice. In particular, the experienced clinician has the wisdom to acknowledge their own limitations and thereby know when to ask specialists for advice and refer their clients to them. However, there are many clinicians who can become trapped by their own biases, which certainly can help their specific group of clients. Yet, have they had the skills to recognize where treatment hadn't been optimal? Have they contributed to the client ending up on an orbital freeway, unable to get off and explore the town and hence alternative possibilities for reaching their destination through novel management of their condition?


Philosophy and pain

An exciting approach to challenging realities is the examination of the Pain and Philosophy of the Mind (Alex Cahana July 2007, Pain Clinical Updates, Vol XV, 5). Cahana argues that 'mind-body supervenience' (physicalism or materilism) where pain always has a physical substrate, isn't enough to explain the qualitative nature/character of pain ("qualia" = what it is to be).

The problem with physicalism as argued by Cahana is that 'you are nothing but your synapses' ("eliminative") or 'you are ultimately your synapses' ("reductive" or "token").

Cahana (2007) concludes by stating that "pain cannot be separated from the person experiencing it, and the human experience cannot be omitted from a scientific explanation of how our mind works. Therefore, a new subjectivist, interpretive, phenomenological stance is needed in order to capture the complexity of the patient's narrative experience (narrative dyad)".

Thoughts lead to feelings which lead to either action or inaction whereby either activation or deactivation of problem solving takes place. This applies as much to the therapist as to the client who is suffering from pain. Through clinical prediction, environmental prediction can be more finely tuned by the feelings which have preceded the situation that has taken place. The therapist and the client need to embark in cognitive strategies which include ascertaining feelings and beliefs, appraising the adequacy of the response and then if necessary using problem solving to be able to use realistic goal setting (rather than fear -avoidance behaviour) to establish a paced response. Success (by the therapist and the client) leads to better predictive outcomes and thereby should become self-fulfilling.

Figure 1: A model of predictive reasoning which has been propagated in physiotherapy since the early 1990's (based on the work of Barrows & Tamblyn 1980)


Scope of Practice

C.B.T = cognitive behavioural therapy ; N.L.P = neuro-linguistic programming

Figure 2 Multiple hypothesis formation and refinement of management strategies


Pattern Recognition

Ultimately, the clinical reasoning process can be divided into a process of confirmation or negation either through positive diagnostic testing (eg Faber's test, Speed's test etc etc) with their inherent problems of validity and reliability or the process can involve treating a structure and evaluating the outcome by re-examining both the impairment and disability issues which the client presented with. The clients cognitive-linguistic appraisal of outcome can also be evaluated through the re-evaluation of the significant findings from the subjective examination.

Mind maps are a useful guide for the experienced clinician as they not only chunk together information but also provide a sequential structure for processing multiple information. Mind maps can provide a useful schemata for 'brain storming' and lateral thinking. Furthermore, mind maps provide a useful clinical aid to explaining cause and effect to the client, particulalry when multiple sites of pain are present. Links to mind maps of some clinical conditions

As the physiotherapist gains clinical expertise their predictive reasoning or forward thinking should improve. The majority of our cognitive processing occurs in our subconscious whereby routines only change when their is a variation to our expectations. As such, the repeatedly rehearsed, systematic and structured clinical reasoning routine allows for cognitive efficiency. The experienced clinician can 'chunk' clinical patterns into recognizable objects, whereby many variables can be grouped into a meaningful piece of information. Since, the conscious brain can only process one piece of information at any one time, and only hold 6 pieces of information in short term memory, the reduced cognitive demands of 'chunking' allows the experienced clinician to increase the scope of their clinical expertise. Particularly, in more complex multi-dimensional musculoskeletal problems the Musculoskeletal Physiotherapist should be able to apply a multi-dimensional treatment approach. The discerning Musculoskeletal Physiotherapist uses correlations between disability measures with impairment measures such as restrictions in motion, altered form & force closure, inefficient force transmission, as well as cognitive behavioural factors to ascertain whether they are dealing with a familiar or unfamiliar 'clinical pattern'. The validity of each treatment technique is ascertained by their impact on disability and impairment measures. Predictive reasoning and a successful outcome confirms already established 'clinical patterns' or allows for the recognition of a new 'clinical pattern'. This new 'clinical pattern' can then be laid down into the long term memory and be used by the more efficient subconscious reasoning at a later date. Thus, similar to a 'grand master' chess player recalling thousands of strategic moves from famous games, the experienced clinician can recall clinical patterns and the processes needed to confirm these patterns in an efficient manner.

More precise research and formulation of clinical reasoning concepts has come from Mark Jones and his collaborators, in South Australia. Categories of reasoning which an experienced clinicians undertake include

  • Diagnostic reasoning
  • Narrative reasoning
  • Procedural reasoning
  • Interactive reasoning
  • Collaborative reasoning
  • Reasoning about teaching
  • Predictive reasoning
  • Ethical reasoning

Hereby, they have presented arguments for undertaking research paradigms which provide evidence for the superiority of this approach over protocol recipe based approaches. Moreover, the clinical reasoning approach supports/validates the use of techniques which improve disability and impairment measures. Hence, the physiotherapist and client can achieve immediate gratification when improvements are demonstrated. Similarly, if improvements are not forthcoming, then the process allows analysis and re-analysis (cognition and meta-cognition) of strategies already undertaken and rational decisions can be made because of the systematic nature of this approach. Thus, both the client and physiotherapist can actively learn during this process.

La Havana, Cuba, 1995

Learning hypothesis

When considering continuing education some issues of neuro-linguistic programming (NLP) may become relevant to physiotherapists.

Neuro = neurological processes affecting thoughts and emotions and subsequent behaviour
Linguistic = communicate with others and influence experience
Programming = internal thoughts and patterns of behaviour that help evaluate situations, solve problems and make decisions.

Achieving excellence requires

  • effective communication
  • motivation of yourself and others
  • thinking positively
  • creating actions to make a difference

OUTCOMES : should be S.M.A.R.T = specific, measurable, achievable, realistic, timeframe

  • Creating a well formed outcome means that your goals are stated positively, is clearly context defined, and identifies the resources you need to achieve your goal. Remember each journey commences with a single step
  • Flexibility is about acknowledging that everyone interprets situations through their own perceptions, thereby creating their own reality. Situations change with an ever-changing environment. Flexibility allows you to gather information from a variety of sources, from different perspectives and from different points of view.
  • Rewiring your thinking involves changing your habits, developing new approaches to old situations, replacing limiting thoughts with enabling ones thereby gaining a new perspective.
  • Language filters include deletion, distortion and generalization.
  • Identify who you are, where your beliefs and values lie, what your capabilities are, and in what environment will your behaviour change when challenging your ability to reach your purpose in (professional) life.
  • Map out a structure which reflects both your personal and professional goals starting from some point in the past and going to some specific time in the future to enable you to be yourself. By identifying your time-line, you will be able to pace yourself as you acquire the tools to reach your goals.
  • To create mastery through self-directed learning you need to go through 4 stages of learning a new skill
    Unconscious incompetence : learning a new skill for the first time, not knowing what you don't know
    Conscious incompetence : realizing what you don't know and what you still need to learn
    Conscious competence : building the new skill and capability, and feeling familiar with them
    Unconscious competence : expertly using the tools like they were second nature (e.g. driving a car)

Hence, the post graduate learning which you undertake should reflect the analysis of yourself.


A word of warning

Consider the Schroedinger's Cat phenomenon where the observer's observations affect the outcome. Clinically, a uni-dimensional approach may always seem to achieve the desired outcome, thereby never really testing yourself, nor encouraging you to improve your clinical competency base. If there is little which you are looking for then there is little which you will see, and that which you see will be what you want to see. Incredibly, some of the people who frequently write the text books aren't clinicians. The most extreme case I know is a physiotherapist with only 4 years clinical experience who is writing a book 'about everything to do with musculoskeletal physiotherapy'. So, try to gain your practical clinical experience from as many sources as you possibly can, as people with a guru status often come with a bias. The best people to teach clinical expertise are clinicians. Particularly, if you are going to undertake post-graduate physiotherapy training make sure that the facilitators are current and have at least 10 years post graduate clinical experience. Peter O'Sullivan at Curtin University and Gwen Jull from Queensland University are two brilliant clinicians which spring immediately to mind. Other people who I've had the good fortune to meet and who have embark on a process of clinical excellence are Alfio Albasini of Ticino (Switzerland), Wim Dankaerts from Belgium, Abrahao Batista from Salvador do Bahia (Brasil) and Luis Henriquez from Santiago de Chile.

The clinician/researcher who is able to construct the question, have firstly realize a problem which requires the framing of a solution through the formulation of possibilities, probabilities, improbabilities and unknowns. Hereby, they are on the road to finding an answer, which along the way may throw up some new and intriguing questions as well as solutions.


Cognitive structure

Importantly, the ultimate cognitive goal for deductive and inductive clinical reasoning is to attain and store knowledge in a coherent and meaningful structure, ready for quick retrieval. In the face of clinical pattern recognition, the working hypothesis can be tested and re-tested and altered as clinical findings come to light.

If there are only

  • 5 primary colours (red, green, blue, black & white),
  • 5 basic notes (A, G, B, D, F)
  • 5 basic tastes (sweet, sour, bitter, savoury, salty)
  • 5 types of intelligence found in literature (scientific, philosophy, serious fiction, history, poetry)

which can give rise to an infinite number of combinations, then what are the quintessential elements of physiotherapy?


Multimodal Treatment approach to enhance the scope of practice

Figure 3: 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. A definition of expertise should encompass the ability to perform accurate predictive reasoning.

Multiple Intelligence

"Gardner defines intelligence as the capacity to solve problems or to fashion products that are valued in one or more cultural settings. MI initially consisted of seven dimensions of intelligence (Visual / Spatial Intelligence, Musical Intelligence, Verbal/Linguistic Intelligence, Logical/Mathematical Intelligence, Interpersonal Intelligence, Intrapersonal Intelligence, and Bodily / Kinesthetic Intelligence). Since the publication of Frames of Mind, Gardner has additionally identified an 8th dimension of intelligence: Naturalist Intelligence, and is still considering a possible ninth: Existentialist Intelligence "- see Wikipedia



Sequence of learning through applied clinical reasoning

Human's are prone to taking short-cuts known as "heuristics". Although they generally serve us well, they often cause clinicians to make predictable errors. Generally, biases favor hawkish advice. These include

  • the optimism bias. People are prone to exaggerating their strengths. People generally believe themselves to be smarter, more attractive and more talented than average. They commonly overestimate their future success. This can lead to "illusion of control" whereby they consistently exaggerate the amount of control they have over outcomes, even when those outcomes are determined by luck or other variables.
  • the fundamental attribution error. Even when people are aware of the possible constraints on another persons behaviour and know a lot about the context in which the client is acting, they often don't take it into account when assessing the client's motives.
  • risk aversion bias. An assumption is frequently made that people are "risk averse" but it turns out that we are predominantly "loss averse". The clinician may be prepared to run a risk in the slim hope of avoiding having to recognise a loss.

Due to the ease of being drawn into 'pattern recognition' and hence potential biasing, it is important for the clinician to maintain a structured cognitive retrieval process whereby recognition of desired and undesired outcomes leads to conformation or negation of the clinical reasoning hypothesis. Hopefully, when negation does occur, it occurs early in the reasoning process; otherwise the treatment management plan can spiral 'out of control' leading to the therapist taking greater and greater risks in the hope for a miracle. Hence, the clinician will need to be able to think back to first principles of anatomy, physiology, neurophysiology, pathology and biomechanics to be able to undertake the process of reasoning required to achieve the desired outcome. This formulation of outcome should in turn be a consequence of the dialogue within the therapist's brain (cognition & meta-cognition) as well as the dialogue between the client and the therapist.

Constructivism describes the process of learning and acquiring knowledge through experiential reasoning. The assumption underlying 'constructivism' is that we are 'life long learners' (3 l's) and that each and every clinical encounter allows a unique opportunity to learn, relearn and refine our techniques as well as reorganise and restructure our knowledge base. Furthermore, constructivist theory suggests that learning occurs which is based on each individuals unique prior experiences. Truth is considered relative to the individuals construct and hence diverges from logical positivism of science where 'truth' can exist alone without reference to the observers perceptions. This is similar to scientific philosophy of 'relative truths' or the 'relativity of knowledge' espoused by Feyerabend (1975), Kuhn (1970), Popper (1963). All of us would agree that science isn't just a collection of laws, or a catalogue of unrelated facts. Rather, it is a creation of the human mind relating to making sense of the world. Hence, in musculoskeletal physiotherapy we must endeavour to match the science with our clinical reasoning which should make sense to the individual or organisations with whom we are interacting.

Candy (1991, p 263) states that "the constructivist perspective differs significantly from the view of knowledge as deriving from a process of copying or replicating." Hence, "we know reality only by acting on it.....The active interaction between the individual and the environment is mediated by the cognitive structures of the individual......and what we learn from the environment is dependent upon our own structuring of those experiences." (Nystedt and Magnusson 1982, p34)

To the constructivist, knowledge is not a precise map of external reality but a schemata or cognitive structure which can be compared or tested to other peoples construction of the same situation through the use of workable hypothesis or templates (Candy 1991, p 265). Domain specific prior knowledge plays a significant role in the process of construction, problem solving and learning. Systematic procedures for problem solving can be learnt which if content and context specific can lead to advanced clinical reasoning where errors in heuristic procedures can be detected immediately through the continuous testing of the working hypothesis and it's evaluation of the relevance of clinical data to the specific problem at hand. Hereby, not only can reliance on 'heuristics' be monitored but new schemata can be construed from the clinical environment when a clinical presentation occurs with which the clinician is unfamiliar.


Heuristics versus Constructivism

Figure 4: A useful instructional model used to describe a 'top-down' clinical approach with a scientific clinical evidence based approach of biomechanics and neurophysiology. Importantly, the cognitive and meta-cognitive aspects of clinical reasoning are only as good as the diagnostic tools available to the therapist. Hence, excellent manual handling skills and refined but diverse treatment techniques (e.g. trigger point dry needling, soft tissue massage, fascial release, muscle energy, exercise prescription, taping, PAIVM's and PPIVM's) allow for a correlated and integrated approach to treatment. Refinement of reasoning techniques requires frequent repetition of experiential learning.


Clinical Reasoning can be a conduit for the deconstruction and reconstruction of information storage and retrieval systems. This systematic approach allows for the redefining of the situational relevance of perceived information into a 'meaningful clinical picture' whereby correlation of information can be used to confirm or negate a 'reasoning (working) hypothesis'. "Mindfulness" and "Mindsight" has been used by Dan Siegler (2010) to describe the correlation of subjective internal realities with external physical realities. Similarly, Geoff Maitland developed a process of clinical reasoning, in the 1970's, whereby the 'meaning' of information is ascertained through the intra-correlation of the subjective experience with the intra-correlated physical presence or being.


Figure 5: Increasing the validity and reliability of the clinical reasoning process by correlating all aspects of the subjective and physical examination into a meaningful clinical picture (pattern recognition) - adapted from Maitland (1986, 1991). Click on above image for further explanations regarding the development of the Maitland concept.

An example of the sequence of physical exmination for a problem in the back-pelvis-hip region. To provide validity of this management approach, the results of the physical examination and treatment must be correlated with the findings in the subjective examination. Hence, meaning and relevance of the physical examination and treatment can only be obtained through the clients 'subjective quantifiable' experience.  In this manner an integrated coherent narrative can be attained by both the therapist and the client, thus allowing a harmonious client-therapist relationship to ensue.



It is important to appreciate that there isn't a linear relationship between impairment and disability. Disability contains quality of life perspectives which has psychological and social constructs as well as the more visible physically measurable impairments. Health Quality of Life (HQoL) gives the physiotherapist with another avenue to pursue evidence-based practice (EBP) which include the third pillar of EBP, patient values. (see O'Connor R 2000 Measuring Quality of Life in Health. Edinburgh: Churchill Livingston. ISBN: 0443073198)


Psychometric evaluation

When traumatic events involving anxiety and/or pain occur, they can be stored in memory using a process which does not distinguish a timeline of activation or extinguishment of the experience. Hereby, previous traumatic experiences can be conceived as a present traumatic experiences causing further fear and anxiety. Ramachandran has suggested that it can be the preoccupation with the trauma that is disabling. Hence, the concept of allostasis has been included in the neuromatrix described previously in figure 3. Psychometric evaluation is now considered mandatory in NSW when treating work accident related cases.

The Oerebro scale is another useful psychometric questionaire which is recommended by Work Cover NSW

Other areas of assessment may include

- visual fields and visual dominance
- spatio-temporal abilities such as juggling
- sport specific physical and psychological aspects

This latter aspect of assessment may include a 'top 10' attributes list compiled by the client/athlete of both physical and mental performance in an ideal world. Then the therapist can ask the athlete to rate their present sport specific perceived abilities. Additionally, their coach may also be presented the same list and ask them to rate the athletes abilities. This is obviously undertaken without the coach seeing what the athlete thought of themselves. Hence discrepancies can be assessed, measured and addressed. Psychological aspects can be addressed by a Sports Psychologist whereas the physical aspects can be addressed in tandem with the Psychologist, Physiotherapist and Trainer.


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.

There are TWO areas of the clients history that are able to give you an accurate prediction of injury

1. Past Injuries – regardless of how long ago the injury happened

2. Current exercise training volume – obviously the higher the training volume the higher the risk of developing overuse and biomechanical injuries.

A good history should include:

a) Past Injuries – especially those that resulted in surgery, joint disturbances and scar tissue

b) General Health – a rundown client does not recover as well and is more prone to overuse injuries

c) Colds and Flu – limited recovery is available when the client is recovering from general and common medical disorders

d) Sporting Background – some athletic populations have common injury areas e.g. tennis players elbows, swimmers shoulders, gymnasts have excessive flexibility and stability issues in their backs and shoulders, and wicketkeepers knees.

e) Exercise History – clients often mention that they exercised in the past but had to stop due to injury – this information is vital as combined with a physical assessment you can identify the causative factors and re-structure their exercise program to avoid the same mistakes again.

f) Current Exercise Problems – is there any current exercise or activity that causes pain during or after the session.

g) Employment History – certain lines of work also have increased risks of injury for certain body parts. Office workers can have muscle range limitations, truck drivers can have back issues due to excessive vibration and carpet layers commonly have knee and back issues.

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 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.

Figure 6 : The application of treatment will vary with the stage, stability, severity and irritability of the condition. The stage describes whether the condition is getting better, worse or staying the same. The stability is considered both mechanically and neurophysiologically. The severity is the impact the injury has on the person's activities of daily living. The irritability defines how easily the symptoms worsen and relates to how quickly they get better. These factors will influence the goals of the client which should direct the aims and objectives of the therapist. In line with Maslow's formulation of individuals 'needs' the process of clinical reasoning and perfection of treatment skills should lead to expertise in the clinical domain and subsequently to a state of "self actualisation" As the physiotherapist's success and treatment scope improve, self actualisation can be attained through their reflective skills, which enables the therapist to recognise 'gaps' in their integrated knowledge base. Such realisation should result in actively seeking the knowledge and/or competency skills required to reduce the size and number of 'gaps'. However, this expertise can only be gained through the 3L's.

Maslow (1971, p43) defined the attributes of "self actualizers" to include

  • the acceptance of self and others
  • spontaneity and naturalness
  • autonomy and independence
  • freshness of perception
  • genuineness in relationships with others
  • creativity
  • positive self concept
  • involvement in a cause outside of themselves


Figure 7 : Defining the aspects of the examination heightens the therapists cognitive abilities and hence clinical agility. Reflective skills as treatment is instigated and outcomes are measured enhances the therapist's meta-cognitive skills (thinking about their thinking)

Figure 8 : Examining the 'cause of the cause' will get to the root of the problem. By deconstructing the problem, clear and precise explanations can be given whereby the aims and objects of treatment commensurate with the goals of exercise

The stage, stability, irritability, and severity will determine treatment options as well as the dose of treatment - here an example for a lumbar radiculopathy is given


Cause & Affect

Treatment is usually directed at the primary problem for which the client has presented. As the primary problem resolves the cause and affect of the injury must be taken into consideration if an holistic approach is to be considered. Low back pain would address issues of thoracic spine stiffness in rotation, lateral bending and inferior lateral chest expansion as these areas influence the lateral movement of the diaphragm during breathing. In turn this affects the use of the oblique stomach muscles, the transverse abdominus and psoas major. Furthermore, the ganglia of the sympathetic nervous system attach to the anterior aspect of the posterior ribs and their function is influenced by rib movement, which can potentially affect the control of muscle spasms and blood flow to the spine and lower limbs. Finally, deep slow lateral breathing reduces the risk of respiratory alkalosis and hence metabolic acidosis which can affect soft tissue integrity. Looking below the lumbar spine, addressing the pelvis and hips using joint mobilizations, soft tissue massage and muscle energy techniques would affect lumbo-pelvic rhythm. Muscle spasms can be addressed by reducing inflammation and/or relieving mechanical pressure on nerve fibres thereby decreasing ectopic impulse generation. Additionally, dry needling and soft tissue massage of the muscle fibres may also be employed. Exercise regimes to complement the specific impairment outcome measures should be integrated into functional exercises which resemble activities of daily living. Naturally, the clients motivational & emotional state needs to be monitored if a collaborative approach to recovery is to be obtained.


Treatment Failure

In most cases musculoskeletal disorders resolve within 6 weeks. Where greater structural damage has occurred, the resolution of impairment and improvement in disability can take 6-12 months. However, in some cases, dysfunction becomes prolonged causing suffering and reduced vitality.

Reasons for failure of resolution are numerous. However, generally they can be classified as simple or complex. Simple problems are localized dysfunction which wasn't managed correctly in the acute phase resulting in disuse impairment and de-conditioning. Such de-conditioning can take on multiple dimensions. Where a simple ankle sprain leads to atrophy of the leg muscles, reduced cardiovascular fitness, increased weight, neurological-immune-cognitive impairment and even metabolic syndrome. Complex problems arise where multiple structures in various locations have been injured in scenarios of major trauma such as car accidents, skydiving, gun shot wounds, etc. Again, the secondary issues of trauma involving whole body function are the consequence of prolonged recovery. In both cases active involvement by the client in the rehabilitation process are paramount. Moreover, the role of the physiotherapist is to reduce impairment and introduce exercise appropriate for the time line of recovery.

Sporting expertise is gained through repetition of movement and avoidance of (and appropriate recovery from) injury. Frequently, being painfree was considerd to be synonymous with recovery. However, researchers at Queensland University clearly demonstrated that recurrences in injury can be the result of continued abnormal motor function.

In some cases neuro-cognitive issues, arising from 'fear-avoidance' behaviour, occur. This is frequently due to altered sensory information processing. In such cases the client is given the appropriate amount of information to load the body to make it stronger. It is paramount to understand that the intensity and duration of pain is usually not commiserate with 'tissue damage'. In fact 'the pain' now has become the pathology.


The Immune System

The immune system, muscle mass and exercise tolerance can have a profound influence on the clients adaptability to stress, exercise and inflammation. The therapist will need to consider the general health of the client, and in particular their lean muscle mass, when assessing and treating the clients problem. The clients lean muscle mass not only determines biomechanical power, the ability to use insulin, resorb lactic acid to pyruvate by the liver and function as the metabolic end product of the electron transfer chain (ETC) in the mitochondria for endurance outputs, it also directly influences the ability to mobilise immune proteins for an inflammatory defense reaction.

The immune system respond in specific ways to exercise prescription. - link to Rome Presentation

The specificity of goal oriented exercise prescription, can be used for positive immune adaptive responses. - link to nutritional supplementation

Goal oriented exercise prescription and health management regimes can be used to aid the client with their predictive reasoning and hence their adaptive allostatic physiological and behavioural responses. - link to neuro-immune response

Cuba, 1995


Forward thinking (predictive reasoning) as it pertains to the gaining of expertise in orienteering, motor learning, avoidance of injury and pain management


Sometimes it is hard to know what you don't know. It's important not to be constrained by dogma. In each case recognize what you know and compare this with what you don't know. Hereby, a risk analysis can be undertaken to establish the wisdom of your treatment. "A wise person knows their limitations". As each day brings a new dawn, plugging the gaps in your knowledge through life long learning (the 3 L's) can be a most satisfying experience. If you study hard and gain clinical insights from as many respected fields of clinical science as you possible can, you will be able to enhance the scope of your practice and thereby prevent burn-out by recognizing and enjoying the greater challenges of holistic musculoskeletal care. This will not only be to the satisfaction of your clients but also to the greater good of your community. However, the path is a long one, where clinical expertise requires at least 10 years of dedicated learning. I've been a physiotherapist for over 20 years and yet every day brings with it a potentially new learning experience.


Explanations and References

Terapia Manual y dolor (Castellano)

Dolor y Inflammacion (Castellano) PDF

Manual Therapie in der Behandlung von Schmerzen (Deutsch)

Tratamento do dor e inflamacao com fisioterapia manipulativa (Portuguese)

The importance of motor learning in the development of the concept of stability (English)

Exercises in map reading for enhanced cognition (forward thinking - predictive reasoning) (English)

Manual therapy in the treatment of pain and inflammation (English)

Nutritional Supplementation in endurance sport

Exercise and the Immune System (English)

Exercise and Type 2 Diabetes (English)

Exercise and Sarcopenia (English)

Fibromyalgia (English)


Examples of the assessment process for clinical reasoning

Beispiel von Klinisches Denken (Deutsch)

Clinical Reasoning Exercise for low back and lower Limb

Clinical example of treatment for functional instability and radicular LBP

A floppy feeling stiff - accompanied by visceral dysfunction - CREST syndrome

Cyclist riding fixed gear with an overactive right iliopsoas and left knee dysfunction

Multifidus dysfunction - a role for examination of the immune response?

Clinical Reasoning for prevention of cramps in a Triathlon

Presentation at the Rome conference in October 2005

Clinical Reasoning Exercise for Neck-Upper Limb

Development of the concepts of stability

Pelvic floor and pudendal nerve pathology

Shoulder instability and "tennis elbow"

Apresentacao Clinica e Perguntas

Cyclist after a severe fall

LBP Treatment Progress


Vascular System

Important vascular issues include those of the vertebral artery in the cervical spine. A commonly held belief is that these incidence (-catastrophic or otherwise) are rare with a prevelance of 1 : 100 000. However, the true number may be much greater, as many catastrophic incidents are under - reported due to medico-legal reasons. In my clinical experience, by 2008 I had seen approximately 12 clients with VBI and a further 8 who had petit mal seizures or vaso-vagal syncope with mobilisations to the first rib. The majority of the clients with the 'classic' symptoms of VBI had either a prior incidence from manipulation of the C/S or had a major accident involving the neck - car accidents prior to seat belts, and horse riding incidents were frequently reported. Even a train crash was reported. By 2008 I estimated that I had seen approximately 60 000 clients. Hence, my 20 : 60 000 ratio suggest a 1 in 3000 chance of coming across a client with VBI.

A form of pins & needles in the feet during cycling may be due to claudication. Such claudication may be the result of damage to vessels of the abdominal aortic. Additionally the branches of the abdominal aorta descending into the leg as well as the leg vasculature may be damaged by trauma and/or systemic complications (e.g. Marfan's syndrome, vascular diseases, etc). These problems may be a medical emergency whereby immediate consultation with a vascular surgeon is imperative.

Virchow's Triad in the aetiology of thrombosis may also be of assistence with differential diagnosis. The 3 variables include

  • Changes in vessel wall (endothelial damage)
  • Changes in blood flow (flow volume/stasis)
  • Changes in blood constituents (state of coagulability)

The latter may include screening questions for blood disordes (thrombolytic ones, C-reactive protein , Leiden Factor V, as well as Thalasaemia and Sickle Cell Anaemia), systemic inflammatory conditions (such as Lupus and Scleroderma), the use of oral contraceptives, smoking, diet and frequent flying.

Taylor & Kerry (2005) quote a paper from Sise et al (1989) reporting an average 2 year delay in diagnosis in young people where 93% could have been diagnosed with simple palpation of peripheral pulses.

from Gray's Antaomy

Vascular complications are potentailly overlooked causes of symptoms. This in part may be due to their relative infrequency compared with other conditions seen by physiotherapists. Futhermore, the symptoms of vascular compromise may mimic those of symptoms arising from musculoskeletal structures. Compromise of a blood vessel to the spinal nerve results in radicular pain. A colleague reported the incidental finding of a family friend's teenage boy whose mother was about to take him to the chiropractor for low back pain. What he noted was the boy had 3 socks on his left foot!!! Immediate examination of the lack of pedal pulses and referal to the A+E department confirmed a diagnosis of spinal artery thrombosis. Unfortunately, most peoples friends aren't astute clinicians that recognise "something which doesn't make sense". Arterial kinking of the external iliac artery during hip flexion whilst cycling (and rowing, skatting and Fjell running) have been known to produce pain affecting the buttock, anterolateral thigh, calf and foot with feelings of paraesthesia and numbness in the toes. Cyclists may also describe the feeling of 'fullness' in the leg and lack of power, cramping and/or ischeamic like fatigue. Although anterior/posterior and lateral compartment syndromes are commonly associated with vascular complications in running, similar type (not necessarily area) of symptoms associated with iliac artery, femoral artery and popliteal artery can be missed during the clinical reasoning process. Generally, symptoms are associated with exertion and external compromise of the blood vessel. Apart from the iliac artery already mentioned other examples include the femoral artery in the adductor canal (b/n the adductor magnus and vastus medialis), and the politeal artery interfacing with the medial head of gastrocnemius. Generally, these conditions are associated with anatomical anomalies whereby the external pressure from repetitive movement gradually damages the external lining of the blood vessel. Besides repetitive microtrauma, any external trauma from an accident needs to consider possible vascular damage or the formation of scar tissue and adhesions which could lead to vascular damage. Other clinical examples, include aortic aneurysm which may be due to valsava type maneuvers. Familial history may also be important in differential diagnosis. Additionally, a history of heavy smoking can lead to internal blood vessel pathology. Similarly, women who take the pill may also be at risk. Aortic stenosis may manifest as a result of arterosclerosis or due to underlying congenital defects. These are screening questions which need to be asked during the subjective examination. During the physical examination, the femoral and pedal pulses should be examined at rest but usually need to be assessed immediately after exercise or in the compromising posture where symptoms normally manifest. Further testing should include ankle blood pressure monitoring of each side. Taylor & Kerry (2005) recommend 20 minutes of rest before testing systolic blood pressure in the left and right brachial artery, posterior tibial and dorsalis pedis and then using the "Ankle to brachial pressure index = Ankle systolic BP / Brachial systolic BP". 1 - 1.2 considered normal, 0.75 - 0.9 indicates moderate disease, 0.5 - 0.75 severe disease and <0.5 is limb threatening. (see: Taylor AJ, Kerry R (2005) Vascular syndromes presenting as pain of spinal origin. Ch 36 in Grieve's Modern Manual Therapy: The Vertebral Column. Ed Boyling JD & Jull GA Elsevier Churchill Livingstone).

The Upper Limb and vascular compromise

from Grays Anatomy

The posture of the cyclist (and rower) may also make these athletes particularly prone to upper limb and head/neck vascular conditions. Additionally, one of the most common cycling injuries involves landing on the shoulder or outstretched hand resulting in possible neurovascular traction injury, direct trauma and/or clavicular fracture. The latter has been associated with trapezius muscle dysfunction which can be a precipitating variable leading to Thoracic Outlet Syndrome (TOS). Symptoms of TOS can include typical symptoms of neck, shoulder, elbow and hand pain. Occasionally, people describe a sense of swelling (or fullness) in the arm, with/without concommitant pins & needles or numbness. Vascular components of TOS may be less prevelant than neurological ones. Yet this may be due to mis-diagnosis as the plethora of tests (Adson's, Allen's Halstead's manoeuver, Roos's EAST test) may be falsely positive or negative and variable b/n examiners. Hence, the examination must use the multitude of variables at the clinicians disposal, both Subjective symptoms & Physical signs - inductive and deductive reasoning, to make sense of the clincal picture. When in doubt and further investigations are required, by using the weight of probability from many variables, it may also make the argument for further testing more convincing to a medical colleague.

Paget - Schroetter syndrome is a deep venous thrombosis of the subclavian - axillary venous system, also known as "effort thrombosis" (Rutherford 1998, Zell et al 2001) and may account for about 3-7% of all DVT's (Taylor & Kerry 2005). The average patient is in their late 20's to early 30's and males present 3 times more commonly than females. Most commonly complain of quick insidious arm pain (70% in dominant arm), with possible supraclavicular fossa and ipsilateral neck pain. Most commonly occurs in activity with repetitve upper arm, over shoulder height, movements. The usual aetiology is Virchow's Triad which means that specific screening questioning is required. Additionally, other risk factors may include thoracic outlet factors such as cervical rib, anomalous first rib, hypertrophy of the anterior scalene, subclavius or pectoralis minor as well as endogenous factors such as activated protein C resistance and anticardiolipin antibodies (Ellis 2000 in Taylor & Kerry 2005).

Taylor & Kerry suggest that observable signs of vascular compromise may include skin pallor or cyanosis - both resting and positional, swelling, and/or superficial venous dilation. Corneal arcus or xanthelasmas (yellowish raises skin changes) around both eyes may be associated with hyperlipidaemia and hypercholesterolaemia. Staining of fingers may be a more accurate indicator of tobacco consumption. Obesity and state of mental awareness may also reflect underlying cerebrovascular state.

Hand and digital examination should also include nail squeezing - indicative of capillary refilling time. These should be perfomed in various positions of potential vascular compromise. Nail abnormalities may be present. Pulses should be tested, stethescope auscultation should be undertaken and the pressure cuff sphygmomanometer and hand held doppler or automatic blood pressure monitor used (Taylor & Kerry 2005).

Taylor & Kerry (2005) argue quite strongly that vascular examination is such a miniscule part of both under-graduate and post-graduate degrees that we may be implicated in delayed diagnosis and initiating innapropriate treatment.

Clinical example : Facial Numbness

Blood Disorders

Thalassemia (British English: thalassaemia) are forms of inherited autosomal recessive blood disorders that originated in the Mediterranean region. In thalassemia, the disease is caused by the weakening and destruction of red blood cells. Thalassemia is caused by variant or missing genes that affect how the body makes hemoglobin. Hemoglobin is the protein in red blood cells that carries oxygen. People with thalassemia make less hemoglobin and fewer circulating red blood cells than normal, which results in mild or severe anemia.

Thalassemia can cause significant complications, including pneumonia, iron overload, bone deformities and cardiovascular illness. However this same inherited disease of red blood cells may confer a degree of protection against malaria, which is or was prevalent in the regions where the trait is common. This selective survival advantage on carriers (known as heterozygous advantage) may be responsible for perpetuating the mutation in populations. In that respect, the various thalassemias resemble another genetic disorder affecting hemoglobin, sickle-cell disease.

Factor V Leiden, also known as Leiden Factor 5 (and sometimes factor VLeiden) is the name given to a variant of human factor V that causes a hypercoagulability disorder. In this disorder, the Leiden variant of factor V cannot be inactivated by activated protein C. Factor V Leiden is the most common hereditary hypercoagulability disorder amongst Eurasians


Differential Diagnosis involving side effects from medication

Drug Side Effects on the Musculoskeletal System

  • muscle stiffness from drug side-effects

- acne treatment with Accutane :

A medical officer sent me the following details

"Roaccutane can cause myalgia and arthralgia, and they found this on DermNetNZ:

Muscle aches (myalgia) especially after exercise. Low backache is not uncommon. Joint aches (arthralgia) especially after exercise can sometimes be debilitating. These symptoms respond to nonsteroidal anti-inflammatory drugs such as ibuprofen.

In MIMs (Australian Drug Directory):

Musculoskeletal and connective tissue disorders. Myalgia, arthralgia and increased serum creatine phosphokinase may occur and may be associated with reduced tolerance to vigorous exercise (see Adverse Reactions).

In clinical trials of disorders of keratinisation with a mean dose of 2.24 mg/kg/day, a high prevalence of
skeletal hyperostosis was noted. Bone changes including premature epiphyseal closure and
calcifications of tendons and ligaments have occurred after administration of high doses for long periods
for treating disorders of keratinisation. The dose levels, duration of treatment and total cumulative
dose in these patients generally far exceeded those recommended for the treatment of acne.

Minimal skeletal hyperostosis has also been observed by X-rays in prospective studies of nodular acne
patients treated with a single course of therapy at recommended doses.

Due to the possible occurrence of these bone changes, a careful evaluation of the risk/benefit ratio should be carried out in every patient and Roaccutane administration should be restricted to severe cases."

- acne treatment

- anti psychotic drugs for bi-polar disorder :

- cholesterol treatment with statins :

  • loss of bone density from drug side-effects

- anti depressant drugs and loss of bone density

This list is not exhaustive. Importantly it highlights the therapists need to be aware of the clients medication use and their possible side-effects.

  • NSAID's

Macrophages are necessary for skeletal muscle regeneration. Pro-inflammatory macrophages stimulate myoblast proliferation, whereas anti-inflammatory macrophages stimulate their differentiation. Macrophages that invade skeletal muscle soon after injury present a specific phenotype, characterized by high expression of TNF-alpha, interleukin-1beta and secretory leukocyte protease inhibitor (SLPI). Non-phlogistic phagocytosis of the apoptotic and necrotic debris switches the phenotype of pro-inflammatory macrophages into anti-inflammatory macrophages. Consequently, there is a high expression of Transforming Growth Factor- Beta (TGF-beta), interleukin - 10 (IL-10), and peroxisome proliferator-activated receptor - gamma (PPAR-gamma) which have been shown to be associated with the resolution of inflammation and tissue repair (Chazaud et al 2009). This may explain the inclonclusive effects of NSAID's for the treatment of DOMS. In fact it highlights the potential inhibitory effects of NSAID's on muscle proliferation when exercise training.


Examples of courses presented

Australian approach to physiotherapy

Aims & Objectives

Brasil e Portugal

Timetable - Brasil


Sul America


  • Neurophysiological Effects of Traction, Rigaku Ryohogaku (2000), 27,4, 128 (Japan)
  • Lumbar Spine Traction: Evaluation of effects and recommended application for treatment (2000), Manual Therapy, 5, 2, 72-81
  • Neurophysiological effects of Manual Therapy (1996), Kinesiologia, (Chile)
  • Neurophysiological considerations of SLR and ULTT (1998), Kinesiologia (Chile)
  • Whole Body Vibration Therapy and Training

Chaos theory and the Butterfly effect from conflicting descending modulating and peripheral input into the neurones of the spinal cord with inappropriate assessment and treatment


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Last update : 22 February 2017


Trending @ Back in B Physio

  • Sat 18 Nov 2017

    Beetroot Juice Increases Human Muscle Force

    Beetroot juice increases human muscle force Beetroot juice has been shown to improve low frequency muscle force independent of Calcium-handling-proteins or REDOX reaction (Whitefield et al 2017, Med Sc Sp Ex, 49, 10, 2016-2024). Further benefits of beetroot juice are thought to include reduction of blood pressure protection from pre-mature aging aiding cancer survival lowering serveral inflammatory markers including interleukin-6, C-reactive protein and tumor necrosis factor alpha stabilising blood suger improving sexual performance anti-arthritic effects blood purification and enhanced red blood cells removing 'bad' estrogens from our blood stream Uploaded : 18 November 2017 F Read More
  • Wed 01 Nov 2017

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  • Sun 15 Oct 2017

    Neuroplasticity in Tendon Dysfunction

    Neuroplasticity in Tendinopathy by Martin Krause A multitude of contributing factors to altered motor control must be addressed when treating tendon dysfunction. What we have failed to consider in the past when dealing with chronic or recurrent tendon issues are motor control problems encompassing corticospinal control of excitation and inhibition as well as belief systems about pain and contextual factors related to imaging.  Research by Ebonie Rio et al (2015) (BJSM Sept 25, 10.1136/bjsports-2015-095215) suggest that the pain state sets up an adaptive pathway whereby the ipsilateral kinetic chain is directly inhibited by reflexogenic pathways, as well as being inhibited by contralateral hemispheric activity. Simultaneously excitation is enhanced in the opposite limb as well as in least in the case of enhanced excitation of the hamstrings in quadricep tendinopathy. If this is true, then so much for training the contralateral limb for 'cross training' purposes! This may also explain why a lot of people seem to have "all their injuries on the same side" (of the body). Furthermore, they recommend enhancing corticospinal drive through the use of 30-60 second isometric holds at 70-80% MVC to load the muscle whilst using isokinetics to load the tendon. Moreover, they recommend the use of a metronome at 60bpm (stages 1 and 2) with a count of 3 up, 2 down for quads, and 2 up, 3 down for calf isokinetics to optimally engage corticospinal drive through the visual and auditory stimuli (also shown by Kohei et al 2012 for motor imagery and M1 stimulation) more Cortical mapping of infraspinatus muscle in chronic shoulder pain demonstrating higher motor thresholds (aMT= activation MT) and hence reduced excitability on the affected side (39 vs 35) (Ngomo et al 2015 Clinical Neurophysiol, 126, 2, 365-371) Cortical mapping of pain and fear. Lots of overlap suggesting that taking away the fear from the pain with clear clinical explanations and a focused goal directed program using specific functional outcomes is important.  Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036,  Uploaded : 18 October 2017 Read More
  • Mon 09 Oct 2017


    Do I need a scan? "a picture tells a thousand words" - not really! by Martin Krause A scan, in it's self, will not improve anyone's condition. The purpose of a scan is to gain more information about the pathology. Sometimes this information may be irrelevant to the management of a patient's condition. For example, if you knocked your elbow on a door frame and suffered a bruise, which was already beginning to resolve, an ultrasound scan may show some minor soft tissue damage, but that was already obvious by the fact of the bruise, and the information gained from the scan has not helped nor changed the management of the bruise. Therefore, the main reason for getting a scan would be because there is concern that the presence of certain pathologies may lead to a change in the medical management. For example, sometimes a rolled ankle can be more than sprained ligaments, and may require surgey or immobilisation in a boot. If the therapists suspects this might be the case, then they will recommend or refer for a scan (probably an X-Ray) to check the integrity of the bones (especially the fibular and talar dome), because if there is no bony damage then the patient can be managed conservatively with taping, exercises, ultrasound, massage, joint mobilisations etc. However, if there is boney damage, for example, then it might be necessary for the ankle to be immobilised in a boot for three - six weeks, for example. This dramatically different medical management depends on the results of a scan, and it is therefore worth doing. However, scans have no predictive value to the presence or severity of pain. Thirty-three articles reporting imaging findings, in the low back, for 3110 asymptomatic individuals were investigated for pathology. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. (Brinjikji, W et al Spine Published November 27, 2014 as 10.3174/ajnr.A4173). Hence, the results of imaging need to be assessed within the context of the entire clinical picture. Frequently too much emphasis is placed on the imaging not only by the clinician but also by the patient. Some people react to pathology seen on scanning as an affirmation of their problem and can either use it to gain clarity and become better or conversely become worse. Moreover, some people find imaging with inconclusive results as a 'panic moment' - "no one knows what is wrong". Similarly, ultrasound imaging of the tendond has good predictive diagnostic and aids in clinical reasoning when it comes to full tears. However, with partial tears it is a totally different 'ball game'. Ultrasound is highly user dependent, with specifically trained musculoskeletal radiologists able to produce high-quality images that may provide more clinically relevant information than those produced by clinicians with less experience in imaging. Sean Docking, a leading tendon researcher at Monash University, cited 7 authors who found pathological tendon chnages in 59% of asymptomatic individuals, whereas he found that 52% of asymptomatic elite AFL sportsmen had tendon pathology on imaging! Furthermore, symptomatic individuals who improved clinically to the point of resuming play, weren't shown to have improvements on imaging. Again, the clinical context and the clinical reasoning can in many instances prove to be the 'gold standard' not the imaging itself, when considering management options. Shoulder supraspintatus tendon pathology, in the abscence of trauma, is known, in many instances, to be a disorder of immune-metabolic compromise of the tendon and bursa. Imaging may show some changes in signal intensity but, unless it's a complete tear, it can reveal neither the intensity nor the severity of pain when taken outside of the clinical context. A thorough physical and subjective examination integrating all the clinical dimensions of the problem will have far greater value than any one single imaging modality. Yet, imaging still should be used in instances of progressive rapid deterioration and suspected serious pathology which may require surgery and/or immediate medical intervention. In summary, sometimes it is worthwhile getting a scan, because the information gained from that scan will determined the type of medical management that is employed. However, at other times, the scan may be unneccessary, because the information may be irrelevant or lead to an incorrect change in medical management, due to over-reporting of 'false positives'. You will be able to make this decision on the advice of your health care professional. On occasions it can actually be detrimental to have a scan, because some patients can become overly obsessed with the medical terms used to describe their scan results, which then can become the major focus for the clinician and the patient, rather than the more prefereable focus on their symptoms and functional abilities. For example, many people have lumbar buldging discs yet have no symptoms, yet sometimes when these patients have an MRI or CT scan, they can develop symptoms because they think they should have pain if the scan says so! Conversely, for some people the results of imaging can have a positive and reassuring affect. Therefore, it is very important to assess a clients attitude to scans before prescibing them so that the patient's expectations are managed appropriately, and not burdened by the additional, sometimes confusing, information supplied by a scan. Uploaded : 10 October 2017 Read More
  • Thu 14 Sep 2017

    Cervical Spine implications in concussion

    Neck aetiology, autonomic and immune implications, exercise and diet in the musculoskeletal physiotherapy management of Post Concussion Syndrome (PCS) by Martin Krause, MAPA, Titled member Musculoskeletal Physiotherapy Association of Australia  A 14 year old boy presented to A&E, in August 2016, after receiving an impact to the head during AFL (Australian Rules Football). Although his SCAT3 scores were relatively mild, he went on to suffer severe lethergy, resulting in a lengthy abscence from school, culminating in a return to school for exams in the first week of December 2016. By December, even a 30 minute walk was extremely fatiguing. To place this into perspective, he had been playing elite academy grade AFL for several seasons and was an extremely fit outdoor adventurer. Confounding Variables : end of season injury and hence no follow up from the academy suffers from Hypermobile Joint Syndrome (HJS) and possibly Ehlers Danlos Syndrome (EDS), however Beighton score 4/9. suffers from food intolerances, particularly to Glutin and diary, but also some other foods. Potential IBS and autoimmune issues. had just gone through a growth spurt (190cm) Imaging : Brain MRI normal Medical Examination : Balance remained impaired to tandem walking and single leg stance. The vestibular occular motor scale showed significant accomodation deficit of 15cm and there was a mild exacerbation of symptoms. ImPACT testing revealed adequate scores and reaction time of 0.65 which is within acceptable range. History : School holidays December - January. Return to school and was placed in the lower academic classes. Prior to his concussion he was a top 10 student at an academically selective high school. Took up basketball and rowing as summer sports. Academic results tanked. Several lower limb Basketball injuries (Feb - April 17') as a result of what apppeared to be muscular imbalances from the relatively recent growth spurt, as well as taking on a new sport. Showed little interest in returning to AFL as no-one from the AFL academy had followed up on his recovery (or in this case lack of recovery).  Current History : September 2017 showed a continued decline in academic levels. School teachers noted an inability to concentrate. Academic results still well below pre-concussion levels. Fatigue continuing to be problematic. Stopped going to school for 7 weeks due to another head impact, but this time at Basketball. Literature Review : Post Concussion Syndrom (PCS) is defined as "cognitive deficits in attention or memory and at least three or more of the following symptoms: fatigue, sleep disturbances, headache, dizziness, irritability, affective disturbance, apathy, or personality change"  One of the known risk factors for Sport Related Concussion (SRC) is a history of concussion. Although, most adults recover from concussion after 10 days, there is evidence to suggest ongoing abnormailities in the brain can pursist well beyond 10 days (Prichep et al 2013, J Head Trauma Rehabil, 28, 4, 266-273). Thus, with the above described symptoms and potential motor control problems, further complications of PCS also appear to be altered proprioception, an increased risk of musculoskeletal injury which in turn can lead to SRC. The following are the results from soccer players. Nordstrom et al (2014, BMJ Sports Med, 48, 19, Predictors of PCS are uncertain. However, the following clinical variables are considered factors at increasing risk. These include prior history of concussion, sex (females more prominant), younger age, history of cognitive dysfunction, and affective disorders such as anxiety and depression (Leddy et al 2012, Sports Health, 4, 2, 147-154). Unlike the 'good old days' which recommended a dark room and rest for several weeks post concussion, the consensus appears to be a graded return to exercise in order to restore metabolic homeostasis. Disconcertingly, highly trained young individuals can find even exercises in bed extremely demanding in the presence of sport related concussion (SRC). Kozlowski et al (2013, J Ath Train, 48, 5, 627-635) used 34 people,whereby 226 days post injury to conclude significant physiological annomalies in response to exercise which may be the result of 'diffuse cerebral swelling'. Researchers have noted lower systolic and higher diastolic blood pressure in PCS (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Due to autonomic dysfunction manifested in altered cardiovascular and pulmonary responses (Mossberg et 2007, Arch Phys Med Rehab, 88, 3, 15-320), wheerby some clinicians have recommended the use of the exercise program for POTS (Postural Orthostatic Tachycardia Syndrome). This is a 5 month program which recommends mainly exercise in the horizontal and sitting positions for 1-4 months, including recumbent bike, rowing ergometer and swimming laps or kicking laps with a kick board. Month 4 upright bike and Month 5 upright training such as a elliptical trainer or treadmill. Other progressive exercise therapies have also included 20 minutes per day, 6 days per week, for 12 weeks of either treadmill or home gym exercises at 80% of the heart rate at which their concussion symtoms are exacerbated. Their programs were individually modified as the heart rate provoking symptoms increased. When compared to the 'control group', this intervention was shown to improve cerebral perfusion on fMRI, increase exercise tolerance at a higher heart rate, less fatigue and were showing activation patterns in areas of the brain on performing math processing test which were now normalised (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Graded exercises could also have included 'motor imagery' as espouse by the NOI group and the work of Lorrimer Moseley (University South Australia) when dealing with chronic pain. Ongoing Symptoms : The literature review by Leddy et al (2012) found that ongoing symptoms are either a prolonged version of concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual disturbance, or some combination of conditions. Anatomical considerations : Extensive anatomical connections between the eyes, neck and vestibular system (Wallwork et al 2007, JOSPT, 37, 10, 608-612) allow sensory information from neck proprioceptors to be processed together with vestibular information which, via the lateral vestibulo-spinal tract, affect the control of postural muscles such as the deep trunk muscles  (Hain 2011, Neuro-Rehabilitation, 29, 2, 127-141).  Psychological considerations : The Kubler Ross model of grief are applicable when it comes to chronic sports injuries. Physiotherapy Assessment : Current history One year PCS, fatigue continued to persist. Cognitive deficits with school work were reported to becoming more apparent. Assessment using various one leg standing tests employing oscillatory movement aroud the hips and knees for kinetic limb stability and lumbopelvic stability, which had been employed 6 months previously for his Basketball injuries were exhibiting strong deficits, despite these being 'somewhat good' previously. Significantly, during the acute phase of SRC, rugby union and rugby league players have been seen with alterations of both balance strategies and motor control of the trunk (Hides et al 2017, Musculoskeletal Sci Pract, 29, 7-19).  Physical Examination : cervical and thoracic spine Due to the Joint Hypermobility Syndrome (JHS) it was difficult to ascertain neck dysfunction based on range of movement testing. ROM were unremarkable except for lateral flexion which demonstrated altered intervertebral motion in both directions. Palpation using Australian and New Zealand manual therapy techniques such as passive accessory glides (upslopes and downslopes and traction) exhibited muscles spasms in the upper right cervical spine. In particular, the right C1/2 regions demonstrated most marked restrictions in movement. Eye - Neck proprioceptive assessment using blind folds and laser pointer also  revealed marked variance from the normal. Repositioning error (RPE) using the laser pointer with rotation demonstrated marked inability to reposition accurately from the left, tending to be short and at times completely missing the bullseye. Gaze stability with body rotation was NAD. Gaze stability whilst walking displayed some difficulty. Laser pointer tracing of the alphabet was wildly inaccurate and cognitively demanding. Thoracic ring relocation testing also revealed several annomalies, which may have also accounted for some of the autonomic dysfunction observed.  Occulomotor assessment and training Upper Cervical Spine : The upper cervical spine (atlas and axis) represents approximately 50% of the available rotation. An investigation into the environmental and physiological factors affecting football (soccer) head impct biomechanics found that rotational acceleration was one of the few factors approaching significance and concluded that more research should be undertaken to evaluate this (Mihalik et al 2017 Med Sc Sp Ex, 49, 10, 2093-2101). Headache : Commonly referred to as cervicogenic headaches, one in five headaches in the general population are thought to be due to the cervical spine. The Upper Cervical Spine is particularly vulnerable to trauma because it is the most mobile part of the vertebral column, with a complex proprioceptive system connecting the vestibular apparatus and visual systems. It also coincides with the lower region of the brainstem and fourth ventricle. The brainstem houses many neurones associated with autonomic responses to pain and balance. Imaging of the fourth ventricle for swelling of the 'tonsils' and Arnold Chiari malformations are recommended when symptoms persist. In particular, children and adolescents are more vulnerable to neck contusions due to the proportionately larger head and less developed musculature. Cervical vertigo and dizziness after whiplash can mimic symptoms of PCS.. Mechanoreceptor dysfunction and vertebrobasilar artery insufficiency should be part of the differential diagnosis. Mechanical instability of the Upper Cervical Spine should also not be missed. Cervicogenic Headaches Further Interventions : Neurocognitive rehabilitation of attention processes. Psychological intervention using cognitive behavioural therapy (CBT). Neuro-opthalmologist to assess and treat smooth pursuit eye tracking. Naturopath for food intolerances and dietician for the optimisation of diet. Diet :  In cases with chronic fatiguing factors, nutrition can be become a vital aspect into the reparative process. This may include energy and mineral rich foods such as bananas, green leafy vegetables for iron and magnesium (200-300mg), oranges for vitamin C (anit-oxidant and helps with the absorption of iron), anti-oxidant rich foods such as EPA/DHA (1000mg) fish oil, curcumin (tumeric), Cats Claw, Devils Claw, Chia seeds, fruits of the forest (berries), and CoQ10 with Vitamin B. Folate and Ferritin levels should also be checked. Calorific energy intake should balance with energy exependiture. However, as we are often dealing with young individuals, as in this case, some form of comfort food may be appropriate such as, nuts, legumes, homus and sushi. Protein intake prior to carbohydrate intake may help ameliorate any blood suger fluctuations due to Glycemic Index factors, however simple carbohydrates (high GI) should be avoided wherever practical. Even oats need to be soaked overnight and cooked briefly, otherwise they become a high GI food and may even affect the absorption of iron. The type of rice used can also influence GI, hence the addition of protein such as fish. Protein supplementations are generally over-used. Daily protein intake should not exceed 1.2g per kg of body weight per day. Dosage for children is less than that for adults. See Nutritional Section of this Site Trunk muscles : Researchers have found that a history of SRC had an increased possibility of having altered size and contraction of their trunk muscles, incuding smaller multifidus, larger quadratus lumborum muscles, and asymmetrical contraction of their transverse abdominis muscles, whereby an increased thickness and resting tone of the right anteroloateral abdominal muscle has been observed (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). In this case, by the second incident (Basketball impact), the subject was 15 years of age and 193cm in height. Apart from being very tall for his age he also has joint hypermobility. Combinations of SRC, growth spurt and hypemobility may have had a greater impact on his motor performance making secondary trauma more likely? A 3-6 increased risk of future SRC has been reported in the literature in cases of concussion (Abrahams et al 2014, Br J sp Med, 48, 2, 91-97). In our subject, using the laser repositioning error described above, marked inability to reposition the neck from the left was seen. This concurs with the findings in Australian Football Players (AFL), where a mean of 4.5 degrees of joint position error was reported on the left hand side (Hides et al 2017 Med Sc Sp Ex, 49, 12, 2385-2393). This is noteworthy, as our subjects initial concussion took place during AFL, with the subsequent concussion occurring in Basketball. It should also be remembered that this subject presented to physiotherapy for an ankle injury some 6 months after the initial concussion. Lower limb kinematic exercising ability, emphasising global balance and kinematic 'inverse dynamics' muscular energy strap transfer prinicples, demonstrated strength and balance deficits within the following prgramme. It should be noted that this regime places emphasis on repatitive loading; hence 3 x 40 reps. Interestingly, an investigation comparing lower limb (LL) and back exercises (lumbar extension LE and lumbar stabilisation LS) for runners with chronic low back pain reported  greater improvement in self-rated running capability and knee extension strength in the LL group vs LE and LS groups greater increase in running step length in LL and LE groups and similar reductions in running induced pain and improvement in back muscles across all three exercise groups. (Cai et al 2018, Med Sc Sp EX, 49, 12, 2374-2384) Extrapolation of these results to the current clinical setting suggests the importance of lower limb dynamic stability in cases of concussion. Moreover, recognition of these deficits may have prevented the second incidence of concussion? Conclusion  Investigations, into people with persisting PCS, demonstrated that they applied more force over time to control balance. Helmich et al (2016, Med Sc Ex Sp, 48,  12, 2362-2368) proposed that in regard to cognitive processes, the increase of cerebral activation indicates an increase of attention demanding processes during postural control in altered environments. This is relevant in so far as individuals with post concussive symptomatology have a variety of symptoms including headache, dizziness, and cognitive difficulties that usually resolve over a few days to weeks. However, a subgroup of patients can have persistent symptoms which last months and even years. Complications in differential diagnosis, can arise clinically, when neck dysfunction and altered motor control occur concurrently due to both neck and cerebral pathology. For example, Whiplash and other traumatic head and neck injuries can result in pathology to both regions, whereas, more discreet altered cognitive processing from concussion can result in altered neck motor control. Musculoskelatal Physiotherapy can play a vital part in the treatment of neck dysfunction including the re-establishment of occulomotor proprioception and managing localized strength and cardiovascular exercise regimes. A total body, multi-disciplinary approach which is well co-ordinated amongst practitioners is vital to an optimal outcome.    Updated : 10 February 2018. Original : 17 November 2017 Read More
  • Thu 24 Aug 2017

    Pain in the Brain - neural plasticity

    Pain in the Brain and Neural Plasticity by Martin Krause There are several mechanisms that can create a sensation of pain, which has been described as 'an unpleasent sensory and emotional experience in response to perceived or potential tissue damage'. Pain can be the result of peripheral sensitisation from peripheral inflammation, vascular compromise, necrosis, swelling, etc. Importantly, higher centres of the central nervous system not only perceive such sensitization of the peripheral nerve receptors, they can also modulate and control the intensity and tolerability of the perceived sensation through descending modulation at the peripheral receptor and in the spinal cord and through transcortical mechanisms depending on the 'meaning' and 'context given to the pain. Moreoever, the higher centres can create a 'state' of perceived 'threat' to the body through emotions such as fear and anxiety. Rather than the brain acting as a filter of unwanted sensation, in the higher centre induced pain state, rumination and magnification of sensations occur to create a pathological state.  Paradoxically, representation of body parts such as limbs and individual muscles can reduce in perceived size. In such instances the pain doesn't represent the sensation of pathology but rather pain has become the pathology. Hence, the brain generates pain in the brain, where the pain is perceived to be some sort of non-existant inflammatory or pathological sensation in the periphery. Evidence for this neural plasticity comes from imaging studies, where brain white matter structural properties have been shown to predict transition to chronic pain (Mansour et al 2013, Pain, 154, 10, 2160-2168). Specifically, differential structural connectivity to medial vs lateral prefrontal cortex and connectivity between medial prefrontal cortex and nucleus accumbens has been shown in people with persistent low back pain. In this case the back pain becomes the inciting event and given the persons' structural propensity, establishes specific functional coonectivity strength.  further reading Peripheral input is a powerful driver to neuroplasticity. Information gathered by touch, movement and vision, in the context of pain can lead to mal-adaptive plasticity, including the reorganisation of the somatosensory, and motor cortices, altered cortical excitability and central sensitisation. Examples of somatosensory reorganisation come from the work of Abrahao Baptista when investigating chronic anterior knee pain, who not only demonstrated reduced volume of Vastus Medialis but also is cortical translocation to another part of the cortex. ndividuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036,   AKP = anterior knee pain The same researcher (Abrahao Baptista) has shown that maximal tolerable electrical stimulation (eg TENS) of muscles can induce normalisation of the cortical changes through a process called 'smudging'. Transcortical stumilation has also been applied as a cortical 'primer' prior to the application of more traditional therapy such as motor re-training, exercise, and manipulation. Body illusions are another novel way to promote the normalisation of cortical function through adaptive neuroplasticity. Examples come from people with hand athritis, whose perception of their hand size is underestimated (Gilpin et al 2015 Rheumatology, 54, 4, 678-682). Using a curved mirror, similar to that in theme parks, the visual input can be increased to perceive the body part as larger (Preston et al 2011 DOI: 10.1093/rheumatology/ker104 · Source:PubMed ) . Irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand (Whitkopf et al 2017, Exp Brain res, 23, 5, 1933-1944). These visual inputs are thought to affect the altered functional connectivity between areas of the brain thereby affecting the 'pain matrix'. Another, novel way of looking at movement and pain perception is the concept of the motor engram. This has been defined as motor skill acquisition through the modification and organisation of muscle synergies into effective movement sequences. The learning process is thought to be acquired as a child through experientially based play activity. The specific neural mechanisms involved are unknown, however they are thought to include motor map topography reflecting the capacity for skilled movement reorganisation of motor maps in a manner that reflects the kinematics of aquired skilled movement map plasticity is supported by a reorganisation of cortical microcircuitry involving changes in synaptic efficacy motor map integrity and topography are influenced by various neurochemical signals that coordinate changes in cortical circuitry to encode motor experience (Monfils 2005 Neuroscientist, 11, 5, 471-483). Interestingly, it is an intriguing notion that accessing motor engrams from patterns aquired prior to the pain experience might lead a normalisation of brain activity. My personal experience of severe sciatica with leg pain, sleepness nights and a SLR of less than 30 degrees, happened to coincide with training my 9 year old sons soccer training. I was noticing that the nights after i trained the children, I slept much better and my range of movement improved. I commenced a daily program of soccer ball tricks which i had been showing the kids, including 'juggling', 'rainbows' and 'around the worlds'. Eventually, I even took up playing soccer again after a 30 year abscence from the sport. Other than new activity related pain issues (DOMS), four years on, the sciatica hasn't returned. I can only conclude that this activity activated dormant childhood motor engram, worked on global balance, mobilised my nerve, encouraged cross cortical activity and turned my focus into finctional improvement. Further explainations for my expereience comes from evidence suggesting that a peripheral adaptive pain state is initiated, whereby transcortical inhibiton occurs by the contralaleral hemisphere to the one which controls the affected limb. Additionally, excitation cortical (M1) drive of the muscles of the contralateral limb to the one which is in pain also occurs. In such cases re-establishement of motor drive to the affected side is important. In terms of tendon rehabilitation, external audtory and visual cues using a metronome have been employed and are showing promising results (Ebonie Rio et al 2017 Personal communication). In terms of my experience with the soccer ball tricks, the external visual cues and the cross talk from using left and right feet, head, shoulders, and chest during ball juggling manouvers, whilst calling the rhythm to the kids may have been the crucial factor to overcome the dysfunctional brain induced pain - muscle inco-ordination cycle, which I was in. Additionally, I was cycling which allowed me to focus on motor drive into the affected.limb. However, work by Lorrimer Moseley on CRPS has established that 'brain laterality' must be established before commencing trans-cortical rehabilitation techniques. Lorrimer's clinical interventions use 'mirror imaging' techniques which are only effective once the patient is able to discriminate the left and right sides of the affected body parts, presented visually, in various twists and angles.   Alternatively, the altered pain state can result in a hostage like situation, whereby the pain takes control. Similar to the 'Stockholm Syndrome' where the hostage begins to sympathise with their captors, so do some peoples brain states, where it begin to sympathise with the pain, creating an intractable bondage and dysfunctional state. One screening question which may reflect commitment to the process of rehabilitatation is to question whether they were able to resist the cookie jar when they were a child? Or were they committed to any sporting endeavours as a child? This may give some indication for the presence of motor engrams which can be used to overcome dysfunctional pain induced muscle synergies (neurotags), but also indicate an ability to be self disciplined, as well as being able to reconcile and identify goal oriented objectives, in spite of the cognitive pain processes? Remember that neurons that fire together, wire together. Uploaded : 18 October 2017 Read More
  • Thu 03 Aug 2017

    Sickle Cell Trait and Acute Low Back Pain

    Researchers believe that lumbar paraspinal myonecrosis (LPSMN) may contribute to the uncommon paraspinal compartment syndrome and that sickle cell trait (SCT) may play a role. Sustained, intense exertion of these lumbar paraspinal muscles can acutely increase muscle size and compartment pressure and so decrease arterial perfusion pressure. This same exertion can evoke diverse metabolic forces that in concert can lead to sickling in SCT that can compromise perfusion in the microvasculature of working muscles. In this manner, they believe that SCT may represent an additional risk factor for LPSMN. Accordingly, they presented six cases of LPSMN in elite African American football players with SCT. See link below Read More
  • Thu 03 Aug 2017

    Ibuprofen, Resistance Training, Bone Density

    Taking Ibuprofen immediately after resistance training has a deleterious effect on bone mineral content at the distal radius, whereas taking Ibuprofen or undertaking resistance training individually prevented bone mineral loss. Read More
  • Tue 11 Jul 2017

    Mitochondrial Health and Sarcopenia

    The aging process (AKA 30 years of age onwards), in the presence of high ROS (reactive oxygen species) and/or damaged mitochondrial DNA, can induce widespred mitochondrial dysfunction. In the healthy cell, mitophagy results in the removal of dysfunctional mitochondria and related material. In the abscence of functional removal of unwanted mitochondrial material, a retrograde and anterograde signalling process is potentially instigated, which results in both motor neuronal and muscle fibre apoptosis (death) (Alway, Mohamed, Myers 2017, Ex Sp Sc Rev, 45, 2, 58-69). This process is irreversible. Investigations in healthy populations, have shown that regular exercise improves the ability to cope with regular oxidative stress by the buffering and 'mopping up' of ROS agents which are induced as a result of exercise. It is plausible and highly probable that regular exercise throughout life can mitigate against muscle fibre death (Sarcopenia). Importantly, this process of muscle fibre death can commence in the 4th decade of life. and be as much as 1% per year. Reduction of muscle mass can result in immune and metabolic compromise, including subclinical inflammation, type II diabetes as well as the obvious reduction in functional capacity for activities of daily living. Published 11 July 2017 Read More
  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) by Martin Krause When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. An interesting case of EDS and it's affect on post concussion syndrome can be read elsewhere on this site. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 17 October 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More

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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected