Clinical Reasoning and the development of a 'working hypothesis' in an elite cyclist
by Martin Krause (2010)
Treatment: Left and right ischiococcygeus release; MET right adductor; in prone with one foam role under right hip and another under the left ASIS I used joint mobilistions, STM and dry needling to the right erector spinae group from T12 - L3. Exercises included Prone Spinal Extension (McKenzie), self release of ischiococcygeus, deep abdominal and iliacus stabilisation exercises during knee drop outs in supine, unilateral pelvic rotations/gluteus activation in supine, cross country skiing exercise with blue theratubing
see link to evidence for dry needling
17/03/2010 (4 weeks since accident)
Less painful walking on stairs
MRI findings : non-displaced fractures of the acetabulum
Very little lumbar IVM during lateral flexion, flexion and extension.
Treatment : STM right anteriomedial hip
Joint mobilisations to right T12-L3
Exercise : Sideways stepping (later off a small step), Prone - gluteal activation during initiation of ALE (active leg extension), Swiss Ball - supine bridging for gluteal activation, 'around the world' in side lying using low threshold activation to rotate the ball whilst keeping the pelvis steady; 4 Point Kneeling - abduction and abd/ext rot, lying prone on foam blocks for pelvic alignment (right anterior hip and left anterior pelvis).
No pain on stairs. New seat on bike making him less stable.
Left Concave scoliosis present on forward flexion, poor IVM lumbar spine. Excessive activity in all superficial trunk muscles and hip muscles. More marked left concave scoliosis on the bike. Excessive pelvic rocking to the right in the horizontal plane, whilst dropping the left hip in the saggital plane. Corrected through transverse pressure through the R6-8 rib rings whilst lifting the posterior right R9-12 rib rings.
Treatment : commenced MET's for upper lumbar/low thoracic right rotation; left rib ring lifts R7-8. Right iliopsoas releases.
MET left hamie for correction of left anterior ilial rotation
Exercises : Pilates Reformer - hip abd, ext in standing, superman with lateral and inferior diaphragmatic breathing
Transverse Adbdo - deep Multifidus training using 'guy wire through body suspending the spine' analogy.
Active Leg Extension (ALE) using 'guy wire stabilisation', descending diaphragm and 'Relaxation with Awareness' technique on the low-mid thoracic and upper lumbar spine erector spinae muscles. Stretching thoracic spine with stretches of the hip flexors, hamies and calf muscles
Further treatments on 30/3/10 , 7/4/10 and 14/5/10 as above, however now with even more thoracic emphasis, plus a big emphasis on detraining the superficial muscles, activation of the pelvic floor - diaphragm as well as gaining 'timing' w.r.t lumbopelvic rhythm in the frontal and horizontal planes.
Client becoming rather anxious to get back on the bike. Wife not too happy to have a moody husband 'hanging about the house' Hence gradual recommencement of cycling during this period
Jay returned 2 1/2 months after the last treatment stating that he had been suffering severe knee pain for the past 2 weeks. It had been of an insidious onset. However he had had a bike fit some 6 weeks prior to the onset of knee pain. At the time he had experienced some mild burning pain in the left ribcage after the new set up. He described 3 distinct pains in the leg - one sharp, the other a dull ache, whilst another sensation was that ' of the whole leg feeling dead'. Dull ache at night. Pain in mid popliteal region during push-off phase of walking. Pain in both the posterior knee and posteromedial knee during the upward cycle through Top Dead Centre (TDC) to 1/2 Bottom Dead Centre (BDC).
Extension in lying (modified push up, McKenzie technique) was reduced to 1/4 in the L/S
All hip ROM were once again restricted. The One Leg Standing (OLS) demonstrated an Intrapelvic Torsion (ITP) right, with reduced form closure over the left SIJ.
Importantly, the ITP right was accompanied by horizontal pelvic rotation right (contrary to normal clinical prediction) and the left concave scoliosis is on the side with the longer leg!!
SLR with DF was approx 45 degrees and without DF approx 60 degrees on the left and 60 and 70 degrees on the right resp.
Active SLR +ve : better with left R6-9 ring lifts and/or right anterior rib posterior translation
Hip flexion in sitting : In sitting he was unable to lift either leg beyond 90 degrees hip flexion. Lifting on the left resulted in left pelvic shift, on right resulted in right pelvic rotation, these were accentuated on the bike and were acompanied by a left concave scoliosis in the L/S.
The sacrum was vertical and the low lumbar spine was nearly vertical, with severe wedging into flexion occuring at L2/3 and L3/4 whilst seated on the bike.
Localised tenderness and swelling was present in the popliteus muscle. The semimembranosus, semitendinosis, gracilis and tibial nerve were all tender to palpation.
Active Leg Extension (ALE): severly reversed Glut : Hamie timing. Extremely hamstring dominant with associated excessive tension in the erector spinae of the low thoracic and high lumbar spine.
Typical EMG patterns : note the need for Gluteus Maximus activity during the downward pushing phase of cycling. My thoughts were that lack of early Gluteus Max timing and constant use of Hamstrings were overloading the structures around the knee. Additionally, the semimembranosus and semitendonosis internal rotation vector at the tibia being a counter to the adductor vector of hip internal rotation. Moreover, these were preceded by counter-nutation at the left SIJ. Anterior rotation of the ilia makes it particularly difficult to activate the gluteus maximus. Moreover, anterior rotation of the left ilium would create tension in the ilio-lumbar ligament normally resulting in right rotation of L4, where this was accompanied by a significant counter posture of left concave scoliosis in the upper lumbar spine and low thoracic. The wedging at L2-4 may also have been placing Adverse Neural Dynamics on the obturator nerve.
Link to ALE and ASLR and diaphragm
A program to regain pelvic symmetry and thoracic mobility was instigated using a comibination of joint mobilisations, MET's, dry needling, soft tissue massage, and rib ring lifts. Additionally, Adverse Neural Dynamics signs were treated using techniques to the thoracic spine.
Link to motor control and breathing reference
Scapulo-lumbar stabilisation exercises were also given by using theraband whilst using the bike on the 'home trainer' . Hereby, activation of latissimus dorsi and low fibres of trapezius was instigated which resulted in reduced horizontal rotation of the pelvis during pedaling.
Alexander Technique for Lumbopelvic, Thoracolumbar and Scapulothoracic support through elongation of the Upper Cervical Spine
This author used 3 sessions of treatment to the T10/11, T11/12, T12/L1 and L5/S1 to improve the ROM and ability to squat in a patient with anterior knee pain.Grindstaff TL et al (2009) Effects of lumbopelvic joint manipulation on quadriceps activation and strength in healthy individuals. Manual Therapy, 14, 415-420.
These investigators found a significant increase in the ability to produce quadriceps force (+3%) and activation (+5%) immediatley following lumbopelvic joint manipulation
Figure 1: A model of everything : the neuromatrix is used as a model (cognitive process oriented structure) to describe the various input which the therapist can offer to 'enable' the client to engage in their path to recovery. Hereby, an evidence based approach using 'the values and beliefs' of the client is integrated with the scientific evidence base from physiotherapy, the pain sciences and psychology. Importantly, the therapist gains confidence through their success at predictive reasoning, whilst the client gains emotional confidence in their ability to undertake goal-oriented activities without the fear of exacerbation or under-performance.
Heuristics versus Constructivism
Figure 2: A useful instructional model used to describe a 'top-down' clinical approach with a scientific clinical evidence based approach of biomechanics and neurophysiology.
Figure 3: Increasing the validity and reliability of the clinical reasoning by correlating all aspects of the subjective and physical examination into a meaningful clinical picture (pattern recognition) - adapted from Maitland (1986, 1991).
Treatment as a product of a systematic assessment
Although an at 'out of fashion' terminology, the aggravating/easing factors are a disability measure which can be used to assess the neurophysiological and biomechanical state of the pathology. By analyzing the movement and loading characteristics of the aggravating and easing factors the therapist should gain a measurable outcome tool for assessing the efficacy of treatment. Additionally, the information can be used to correlate it with impairment measures of the physical examination. Improving the internal reliability by correlating information across the entire examination process enhances the validity of your treatment and re-examination process. Ideally, the therapist should have at least 3 aggravating/easing factors to assess outcome. Otherwise, a more in depth analysis of the aggravating/easing factors should be undertaken using inductive reasoning. For example, if the client only complains of shoulder pain when lifting a load above their head, then clarify this statement by asking whether it is the movement which is painful, the duration of lifting, the manner of lifting or the size of the load which is being lifted that is significant. Night pain, the frequency of waking and the ability to return to sleep are also useful measurement tools. Psychometric disability measures can also be used if they don't result in resentment or irritation from your client.
Further aspects of the subjective examination can be used to assess the past history as it relates to the current problem. Is it the same problem re-aggravated or is it a new problem which is influenced by the old injury? Assess the biomechanical aspects of the original mechanisms of injury as well as those of re-exacerbation, as well as the frequency of exacerbation and make a judgement as to whether the problem is getting worse, better or staying the same. If it is getting worse, then why? Are there components of misuse (reduced co-ordination/stability), disuse (atrophy and reduced capacity of loading), abuse (trauma), or overuse (repetitive loading and microtrauma) which are contributing to the 'cause of the cause' of the problem. A long history of problems may identify fear-avoidance behaviour and generalised 'disuse' and/or of more specific 'disuse' of the multifidus and transverse abdominis muscles. Combine this with 'overuse' of the erector spinae muscles leading to excessive compression of the intervertebral disc and consequent neural irritation of the dorsal root ganglia resulting in ectopic impulse generation and increased muscle tone in the deep hip rotators, hip flexors, hamstring and calf muscles which creates 'misuse' of the lower limbs ('the tail that wags the dog phenomena') generating shearing and rotating forces across the pelvis.
Old injuries may not only reduce the biomechanical integrity of the tissue but it may also increase the neurophysiological sensitivity of the neurones whose nerve fibres innervate the territory of 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 4: 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.
Figure 5: 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 6: Defining 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 commiserate the exercise goals
Cause & effect
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.
Explanations and References
Manual Therapie in der Behandlung von Schmerzen (Deutsch)
Terapia Manual y dolor (Castellano)
Tratamento do dor e inflamacao com fisioterapia manipulativa (Portuguese)
Manual therapy in the treatment of pain and inflammation (English)
Exercise and the Immune System (English)
Exercise and Sarcopenia (English)
Examples of the assessment process for clinical reasoning
Beispiel von Klinisches Denken
Clinical Reasoning Exercise for low back and lower Limb
Clinical example of treatment for functional instability and radicular LBP
Clinical Reasoning Exercise for Neck-Upper Limb
Apresentacao Clinica e Perguntas
Presentation at the conference in Rome in October 2005
Neurophysiological Effects of Traction, Rigaku ryohogaku (2000), 27,4, 128 (Japan)
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Neurophysiological effects of Manual Therapy (1996), Kinesiologia, (Chile)
Neurophysiological considerations of SLR and ULTT (1998), Kinesiologia (Chile)
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