A PROCESS APPROACH IN MANUAL AND PHYSICAL THERAPIES BEYOND THE STRUCTURAL MODEL – FORUM 2

Hi All
Warm welcome to CPDO at Home online live forum. Please feel free to ask any question regarding the Process Approach article. Remember that at the end of the session you can claim 1 CPD credit learning with other.

I would value your comments, thoughts or ideas for future online workshops. Are there particular topics that you felt were missing from the article and discussion?
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What would be good low loading activities for acute lsp disc prolapse?

Hi,
i read the paper, and was a bit taken aback. It seemed to be saying that what we learned at college was now defunct.
That it is not possible to change someone’s structure at all? |I looked at one of the papers that were referenced, about achilles tendons, and thought that the result showed that it was possible to make a change?
Sue.

I am reading the notes now as only saw email a little while ago so sorry if i ask any questions that are answered later on.

Hi Suzeaustin i thought the same about it questioning all we were taught

It sounded a bit like any touch we applied would be as any layman could do. Itfeels a bit like we need to become physios in order to support change.

Yes, there are problems with the models used in teaching for all manual therapy disciplines. For that reason we need a new model such as the proposed Process Approach.

Concerning the Achilles tendon, change was possible only through active exercise that exceed the forces of daily activities.

Are there particular areas where you indentify conflicts with you education? You have mentioned change in structure. This is why we need to focus on process which are more “malleable” than structure.

We were taught that we could make change by using passive movements, not just active, but the article suggests otherwise.

I have had a broken knee, and for a couple of months, used exercises only (a lot!), plus attempts to perform normal day to day activities. However, it was only when I visited by manual therapy physio that I managed to start getting knee flexion. This appeared to be brought about quickly by passive force and soft tissue.

Hope you are all still there:-))
To suzeaustin:
Yes, the touch effects have not been invented by osteopaths; they are part of evolution and human “social physiology”. We utilise this biological phenomenon in our treatment. Layman also stretch and move, but it doesn’t mean that there is no longer professional need for these therapeutic modalities. Remember that your clinical knowledge is more than the sum of your techniques!
Just because active movement is essential for adaptation does not mean that it is physiotherapy. They also have serious lack of understanding about various principles in movement and structural adaptation. I know this because I teach this to physios all over the world!

I find a balance of both manual therapy and functional exercises works as exercise alone is not always possible as the exercises often cause pt too much pain

if I showed a patient’s partner what to do, then his treatment would be as effective as mine? Which eans that my manual skills are not required, just my clinical knowledge? Hard to take….

This was a thought provoking article. I still believe that the structural model has a large role to play in clinical practice, although it is clear that not all patients will conform to this model. For me the structural/biomechanical model is a tried and tested method (that I am comfortable and practiced with) to explain to the patient what has happened and how we are going to remedy that. In my experience, patients appreciate a simple and concise explanation as to why they are in pain what may have contributed to it and how we are going to work towards improvement. (Maybe its just because I am comfortable explaining these things and nothing to do with the model?)

In my opinion the most important thing in our profession is obtaining our diagnosis. This includes tissues responsible for symptoms, state (i.e acute or chronic) and other factors both psychological, mechanical/physical and external. This helps us to tailor our treatment plan.

In the acute phase, the body’s use of inflammation can heal/repair certain injuries. The ‘repair process’ is the greatest of factors having an effect on symptoms and therefore should be targeted as statistically it should be the easiest to change and aid recovery. Conversely in chronic conditions the adaptation process is greatest and therefore should be targeted. In the acute phase a biomechanical approach may be very beneficial but may not work as effectively in the chronic cases. In such cases adaptations physically and psychologically must be considered as the major factor.

The problem with the structural model for me is that it excludes 1) what a person does for the rest of the week/month/year and 2) their psychological components. AT Still said that the body is a unit, we can not be holistic if we exclude such major factors.

Structural change is unlikely to be driven by passive movement/forces. For adaptation you need 3 conditions:
1. the forces imposed must be equal or exceed the forces of daily activities (otherwise our normal daily activity would turn us in a squashy mess)
2. Exposure dependant – have to be repeated many times
3. Specific – they have to resemble the activity the person aim to recover
Think of some going to the gym. In order to bring about a structural change they will have to fulfil these conditions for adaptation. It will not happen with passive movement

I’m not sure I’m ready to abandon the structural model! Though it is definitely the case that the psychological factors are equally as important to address.

Structural change is unlikely to be driven by passive movement/forces. For adaptation you need 3 conditions:
1. the forces imposed must be equal or exceed the forces of daily activities (otherwise our normal daily activity would turn us in a squashy mess)
2. Exposure dependant – have to be repeated many times
3. Specific – they have to resemble the activity the person aim to recover
Think of some going to the gym. In order to bring about a structural change they will have to fulfil these conditions for adaptation. It will not happen with passive movement

To atealeosteo
I agree with many of your observations. However, as a scientist the structural model is hard to defend. As a clinician I have stopped using this model as a diagnosis, a model for treatment or to explain to patients the cause of their complaint.. There is also a danger of Pathologising normality using a structural model “your leg is short, pelvis twisted, spine degenerated, etc.”

So why did my knee start to improve with passive movement rather than loading exercises do you reckon?

Structural change is unlikely to be driven by passive movement/forces. For adaptation you need 3 conditions:
1. the forces imposed must be equal or exceed the forces of daily activities (otherwise our normal daily activity would turn us in a squashy mess)
2. Exposure dependant – have to be repeated many times
3. Specific – they have to resemble the activity the person aim to recover
Think of some going to the gym. In order to bring about a structural change they will have to fulfil these conditions for adaptation. It will not happen with passive movement

I agree that some degree of active involvement is essential for rehabilitation but passive mobilisation techniques have a massive role in enabling a patient to get to that point where they can function sufficiently to perform the right active techniques. Passive mobilisation will not completely resolve the issues in terms of structural changes, but will offer some structural change e.g. friction on a ligament to encourage fibrocyte activity admittedly not as good as weightbearing/propreceptive rehab but some structural change is achieved along with function restoration. I completely agree with points 2 and 3

Re: if I showed a patient’s partner what to do, then his treatment would be as effective as mine?

Yes! But he wouldn’t arrive at this point without all your knowledge!!
Management is more than the sum of you techniques!
(ask yourself what is the difference between what I do and the partner’s care)

What about stretching as part of rehab is this beneficial?

“I agree that some degree of active involvement is essential for rehabilitation but passive mobilisation techniques have a massive role in enabling a patient to get to that point where they can function sufficiently to perform the right active techniques.”

Yes, but it’s by their effect on repair processes and psychological reassurance. This is what the Process Approach suggests..

“I agree that some degree of active involvement is essential for rehabilitation but passive mobilisation techniques have a massive role in enabling a patient to get to that point where they can function sufficiently to perform the right active techniques.”

Yes, but it’s by their effect on repair processes and psychological reassurance. This is what the Process Approach suggests..

Totally agree the structural model is impossible to prove scientifically, but to be honest most things that are multi factorial are! So how do you explain your diagnosis/treatment plan etc to a patient? Yes agreed, I try and be very careful to not pathologise findings. I tend to use humour to diffuse it saying ‘if someone analysed my spine for everything that was “wrong” with it we’d be here all week hearing the report and i’m still alive and standing! Gets a laugh if nothing else

Stretching as part of rehabilitation for restoration of movement has been shown to be clinically ineffective. This has been known for some time, at least for the last decade and a half in research. I would recommend having a look at my book Therapeutic Stretching (see bookshop http://www.cpdo.net, where you can also read the introduction chapters and more. This is why I wrote the book..

Hi All
We are approaching the end of this sessionThis has been a great discussion. Hope you found it useful albeit a bit challenging.
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There will another forum about this topic later this year, will inform you in advance.
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Looking forward to meeting you future forums.
Regards
Eyal

Thanks very much for your paper, which definitely made me think.
Regards,
Sue.

Thank you

Unfortunately I missed the open forum. I found your article fascinating and agree with your overall assessment but as someone who works with a biomechanical/structural model (derived from osteopathy) integrated with a major social/psychological/energetic perspective on the significance and malleability of structure I found many parts of your process model itself less than satisfying.
Throughout the article you present the concept of our body as self-healing through “repair, adaptation and alleviation of symptoms.” Yet clearly many clients do not self-heal and symptoms can continue for years. I have a curiosity about what inhibits healing at both physical and psychological social levels. When you addressed this issue your theorisation seemed too focused on physical parameters. A huge component for me is what I call the “functional benefit” of any particular problem or symptom set, what its social impact is in the life of the client.
Your model of touch effects as “soothe-seeking,” is valid but I think there is also commonly a very large component of general “attention-seeking” and “contact-seeking” within the therapist-patient relationship.