GOAL ORIENTATED PROGRESSION OF TREATMENT:

Goal orientated progression of treatment is most likely one of the most important issues in rehabilitation in general as well as in musculoskeletal management. Several models and modalities of treatment progression have been proposed in literature touching different realms of rehabilitation. Elite sports specific rehabilitation uses, for example, strength and conditioning elements but reconditioning elements and global as well as specific functional strengthening is found to be very interesting to use also with normal patients for many different reasons.

Progression of treatment has been traditionally and historically covered in the Maitland concept, either in the Maitland books and more recently through internet and covers mainly the progression of treatment using manual therapy. The classic Manual Therapy progression scheme used in the Maitland concept is as follows:- Position of treatment

• -Dosage of treatment (grade, rhythm, speed)
• Technique

1. Direction, localization
2. Mobilizations, physiological or accessory
3. Manipulation

• Home program
• Ergonomic program

As clearly stated in Banks' and Hengeveld’s Maitland peripheral manipulation, 2013, 8th edition “passive movement is not a panacea for all musculoskeletal disorders and should be considered in conjunction with other forms of physiotherapy and vice versa”. Several of the Banks and Hengeveld 2013 book’s “visions” on the use of passive treatment modalities have been challenged in the meantime with regards to the “importance” of passive examination and the role of passive movement in rehabilitation. Bank’s and Hengeveld in their book do raise some important questions;

1. “Does the patient have a neuromusculoskeletal disorder”? (probably intended as a dominant peripheral nociceptive disorder?, whereas not all disorders have dominant peripheral nociceptive components!)
2. “is the disorder movement related”? (disorders related to movement do not always imply that the disorder is dominantly related to peripheral nociceptive disorders)
3. “is mobilization/manipulation indicated”? (also very difficult to answer this question since indications of passive mobilization/manipulations are under constant scrutiny and discussion and clear answers to this question are difficult to make)
4. “will mobilization/manipulation fulfil the aims and desired effects of treatment”? (desired treatment effects maybe in itself very restrictive since therapy outcomes do not automatically imply the effectiveness of applied treatment, probably it is better to speak about desired treatment goals and necessary objectives to be able to reach the desired goals)

All these questions, although highly relevant, are under continuous discussion, often personal judgement as well as classification and categorization dependent, with the possibility of creating reasoning flaws, and definitely not easy to answer since there is not always a clear Yes/No answer possible.

Patient’s idea’s and expectations of health care may lead to the patients desire and frequently to the deliverance of mainly passive based therapies and are often related to either prior experience, reward, somatic focus and desire for a “quick fix”. These cultural believes might influence the therapists choice of therapeutic application. Interestingly some models used in traditional health care educations weigh heavily on the peripheral nociceptive/structural side whereas there is a vast and robust body of evidence to consider psychosocial and more “central” related explanations of symptom and pain modulation like for example “conditioned pain modulation”.

The therapists education, “professional culture” and subsequent believes influences and will determine the “therapists reasoning” and in a certain sense “freedom of choice” in the use of therapeutic modalities. These cultural and professional preferences for the use of passive therapeutic modalities may lead to “Internal conflict” as far as rehabilitation principles are concerned; “Self efficacy”; (self actualization, internal reinforcement” and “internal locus of control”, “self observation”, “self reaction” and “compliance” as well as “self evaluation”), and “behavioral change”.

Without doubt physiotherapists encounter in their careers enormous amounts of varieties of patient characteristics, pathologies, injuries, personal needs, requests and so forth. To be able to respond therapeutically to the individual variability of needs and request of patients the therapist must have an enormous amount of available knowledge and resources and need to monitor a great variety of possible progressions of recovery. So let’s highlight some other possible progressions during treatment:

• Spontaneous progression or remission; The natural history of recovery after injury/pathology or disease is in most cases helped if an active lifestyle or “adaptive behavior” is undertaken. One example of adaptive behavior is after physical trauma where several models exist to facilitate recovery like:
  • PRICE (Protect, Rest, Ice, Compression, Elevation)
  • MEAT (Movement Exercise, Analgesics, Treatment)
  • POLICE (Protect, Optimal Loading, Ice, Compress, Elevate) An as active approach as possible (MEAT or POLICE initiating around 48 hours after initial trauma) is in most cases mandatory for speeding up recovery with several positive responses (central as well as peripheral) like immune system responses, encouraged and better functionally organized collagen formation as well as positive psychological, emotional and positive motor output adaptations.
  • Another example is spontaneous regression of symptoms and signs of low back pain. Disc herniations, in most cases, have a spontaneous regression over time.
• Closely related to the above is progression through “Regression to the mean”, “the get better anyway effect” or natural pathways of symptom behavior maybe confounded with therapeutic success.
  • “If a person receives treatment intended to make him better, and gets better, then no power of reasoning known to medical science can convince him that it may not have been the treatment that restored his health”
  • Regression to the mean is a widespread statistical phenomenon with potentially serious implications for health care. It can result in wrongly concluding that an effect is due to treatment when it is due to chance. Ignorance of the problem will lead to errors in decision making. This misleads clinicians and patients into thinking that treatment has been effective and is a call for caution in interpreting patient improvements as causal effects of our actions.
  • Fluctuations irrespective of treatment
  • Natural improvements irrespective of treatments
• Progression through mostly uncontrollable (desired/non desired) effects like “placebo/nocebo effects”    .
  • Expectations/ cultural and psychosocial characteristics
  • Context
    • Non specific treatment effects.
    • Patient/therapist relationship
• Progression of Active Treatment through, Strength and Conditioning, Habituation, Adaptation and Neuroplasticity. It will be very important to have gathered enough information about “where and how” (initial dosage, baseline parameters) to start with your patient. Information about age, general condition and health, activity levels (e.g. sports-related) in daily life as well as initial data gathering through active testing and monitoring of individual capacities facilitates initial dosage calculations in terms of repetitions and sets. Very important is monitoring of weekly/monthly/ tri-mester and further in time, if necessary, progression and specific final and individual goal setting. Obviously the way of testing, the complexity of testing is very much related to the type of patient you encounter, some of the monitoring of progression may need specialized equipment.
  • Increased load ability and improved function/Increased general condition:
    • Increased metabolic rate
      • Metabolic Rate Calculator
      • Progression of Metabolic Equivalent of Task (MET) measurements
  • Reduced BMI and intra-abdominal fat measurements (F.E.: BMI and OA are seemingly correlated in several studies)
  • Increased endurance measurements
    • Endurance monitoring
    • Heart rate monitoring
      • Submaximal testing
      • Maximal testing
  • Progression of strength; Muscle lab, Force plates, exercise parameter like Rep’s/Set’s/Weight/Choice of Exercise/Goal setting
    • 1 repetition maximum to a maximum of 6 rep/max
    • exercises towards fatigue with lower weights may lead to strength increase/endurance/resistance to fatigue ability
  • Strength development programs
    • Dynamic strength index
    • Reactive strength index
  • Progression of power
    • Rate of force development
    • Plyometrics
    •  Speed
      • Timing gates
    • Static assessment (load symmetry and center of pression deviation)
    • Jump (load symmetry, strength, force, velocity, speed, jump height, jump length) monitoring through the use of force plates and biofeedback
      • Squat Jumps
        • Loaded squat jumps
      • Counter movement Jump
      • In place Hops and Jumps
      • One step approach jump
      • Depth jumps
  • Increased agility, skills, motor control and function
    • Balance and Proprioception
    • Stability
    • Movement Dissociation
    • Reactivity, velocity
    • Agility tests
  • Training laws Progression
    • Supercompensation
    • Overload
    • Sustainability
  • Flexibility Progression
    • Functional movement monitoring
  • Aerobic/Anaerobic Progression
    • Increased pulmonary function
    • Increased Oxygen intake, VO2 Max and increased velocity at maximum oxygen intake vVO2Max
    • Increased lactate thresholds
    • Heart rate at rest
      • A potential an indicator of general condition
    • Heart rate under physical stress
    • Capacity of heart rate recovery after physical activity
      • Again both indicators of general condition
      • Autonomic NS parameter
  • Psychological/physiological relationship with own body functions/capacities
    • Psychophysical parameters
    • Conditioned pain modulation
  • Progression of graded exposure
    • Consistency and Variability will facilitate habituation and neuroplasticity

• Progression of Cognition and Behavior during and after Therapy
  • Cognitive reconceptualization of the importance of health and pain
    • Progression of understanding/awareness
  • Compliance
  • Coping strategies
  • Healthy behavior
    • Abolition of pain behaviors
    • Reduction or elimination of psychosocial and lifestyle barriers to recovery
• Progression of improvements in Neurological/Neurosensorial (Quantitative sensory testing) and motor testing
• • Improvements in Sensory loss/reduction
    • Sensory testing
    • Deep tendon reflexes
    • Manual muscle testing
    • Monitoring of altered sensitivity to mechanical-thermal stimulation/mechanical or thermal hyperalgesia or allodynia
    • Pressure Pain Tresholds
      • Maitland concept grading could be used here!
      • Pain Pressure algometer
  • Increased/reduced tolerance to pinprick/brush
    • Temporal summation or wind-up (central sensitization)
    • Hyperalgesia monitoring with Von Frey filaments
    • Two point discrimination returns to baseline levels
    • Cold/Heat stimulation tresholds (non painful and painful)
    • Vibrational sense
  • Progression/regression in Motor Function
    • muscle testing either through dynamometer or manual
  • Neurodynamic testing
    • meccanosensitivity of the nervous system
    • palpation of the nervous system
• Progression/Regression of vestibular function (central and peripheral); Stability and Balance testing or vestibulo-spinal tests: Romberg, Fukuda, Unterberger, Bárány, Babinsky-Weil, Smooth pursuit, motion sensitivity or positional tests, head thrust and head shaking test, Dix-Hallpike test, vestibulo-oculomotor reflexes (VOR), Cervico-ocular reflexes (COR), cervicospinal (CSR or TNR) and Cervicocollic (CCR) reflexes, vestibulospinal (VSR) and vestibulocollic reflexes (VCR), somatosensory reflexes (Nystagmus)
• Progression/regression in psychological/psychophysical states
  • Reduced anxiety and depression
  • Increased capacity of relaxation
  • Quality and quantity of Sleep improvements

Hopefully it has become clear that progression of treatment within a rehabilitation treatment protocol requires many different resources from the therapist. The enormous variability of patients we may see in daily practice forces us to carefully select treatment parameters and progression of treatment. I tried to describe some of the parameters of progression with which I have to deal regularly and some less regularly in my clinical work. There is no claim for completeness! I do hope that this blog may trigger curiosity and awareness of the complexity of working in the health care industry and in special mode in neuro-musculuskeletal rehabilitation.

1. Whitney CW et al, Regression to the mean in treated versus untreated chronic pain, Pain, 50 (1992) 281-285
2. Galton F. Francis Galton and regression to the mean, the royal statistical society 2011
3. Medawar, P.B. The Art of the Soluble: Creativity and originality in science. Penguin Books: Harmondsworth (1969:19).
4. Lucassen P et al, Context as a drug: some consequences of placebo research for primary care, SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE, 2016 VOL. 34, NO. 4, 428–433
5. Finniss DG et al, Placebo Effects: Biological, Clinical and Ethical Advances, Lancet. 2010 February 20; 375(9715): 686–695
6. Bles W, de Jong JMBV, de Wit G. Somatosensory Compensation for Loss of Labyrinthine Function. Acta Otolaryngol (Stockh) 97: 213-221, 1984.
7. Fukuda T. Statokinetic reflexes in equilibrium and movement. U. Tokyo Press, 1984
8. Ito Y, Corna S, von Brevern M, Bronstein A, Grety M. The functional effectiveness of neck muscle reflexes for head-righting in response to sudden fall. Exp. Brain Res. 117 (2) 226-72, 1997
9. Kasai T and Zee DS. Eye-head coordination in labyrinthine-defective human beings. Brain Res. 144: 123-141, 1978. 21. Botros G. The tonic oculomotor function of the cervical joint and muscle receptors. Adv. Otorhinolaryngol. 25:214-220, 1979.
10. Peterson, BW. Cervicocollic and Cervicoocular Reflexes in: Peterson, BW and Richmond, FJ eds. Control of Head Movement, Oxford University Press. New York. p. 90-99. 1988.
11. Pompeiano O. The Tonic Neck Reflex: Supraspinal Control In: Peterson, BW and Richmond, FJ eds. Control of Head Movement. Oxford University Press. New York. p. 108-119, 1988.
12. Kahn E.B. et al, the effectiveness of interventions to increase physical activity. A systematic review, Am J Prev Med. 2002 May;22(4 Suppl):73-107
13. Fersum K.V., Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. Eur. J. Pain Jul;17(6):916-28, 2013
14. Ridehalgh C. et al, Validity of Clinical Small-Fiber Sensory Testing to Detect Small-Nerve Fiber Degeneration. J Orthop Sports Phys Ther. Oct;48(10):767-774, 2018
15. Kline DM et al, Individual Variation in Pain Sensitivity and Conditioned Pain Modulation in Acute Low Back Pain: Impact of Stimulus Type, Sleep, Psychological and Lifestyle Factors. The Journal of Pain 2018
16. Youssef A.M et al, Pain inhibits pain; human brainstem mechanisms, Youssef A.M. et al, NeuroImage 124 (2016) 54–62
17. Gabbett T.J. et al, Debunking the myths about training load, injury and performance: empirical evidence, hot topics and recommendations for practitioners Br J Sports Med Month 2018 Vol 0 No 0
18. Waller M. et al, Various Jump Training Styles for Improvement of Vertical Jump Performance, Strength and Conditioning Journal volume 35, number 1, february 2013
19. Hengeveld E. & Banks K., Maitland's Vertebral Manipulation, 8th Edition, Management of Neuromusculoskeletal Disorders - Volume 1, 2013
20. Hengeveld E. & Banks K., Maitland's Peripheral Manipulation, 5th Edition, Management of Neuromusculoskeletal Disorders - Volume 2, 2013

Comments

You are logged in as {{user.name}}

Name

Email

Your comment {{ comment.length }} / 2000

• {{ error[0] }}

Post Comment