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Maybe I was using this approach all along :)
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
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 movementI 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
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.