The researcher‘s multidimensional manual therapy approach to the management of patients with CNSLBP

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Manual therapy

Manual therapy by definition in this thesis is the release of soft tissues (muscle spasm, taut bands, trigger points and joint capsules, myofascia and neural tissue restrictions – all of which may restrict the skeletal system and contribute to malalignment of the skeletal system) through the direct contact between the patient and the manual therapist‘s hands. It further entails the realignment of the skeletal system by passive oscillatory physiological and accessory movements of joints that do not exceed the normal end-range of joints (Elvey & O‘Sullivan, 2004). Spinal manipulative therapy (SMT) on the contrary entails a sudden available end of range thrust to increase joint range when the window of opportunity presents. A manual therapist would use SMT in combination with manual therapy to release restrictions (scar tissue) in order to integrate other forms of manual therapy to restore alignment, muscle recruitment and function (Haynes, 2003).

Chronicity

Chronicity is the state where the clinical signs and symptoms of CNSLBP become self-sustainable and continuously worsens. Chronicity is categorised in different stages dependent on pain intensity, pain duration and disability due to pain processing (Buchner, Neubauer, Zahlten-Hinguranage & Schiltenwolf, 2007). The non-variable factor in chronicity in patients with CNSLBP is a person‘s genetic make-up which predetermines the extent to which each factor plays a role in the development of chronicity OR the ability to adapt to the condition (Field, 2009; O‘Sullivan, 2005). Clinically it is apparent that some people are set up for the development of chronic pain before the pain starts, while others develop it soon after the acute episode of NSLBP and others drift into it (Field, 2009). Typically the largest group of patients with CNSLBP drifts into chronic pain after trying various available treatment options which did not address their problem adequately (Field, 2009). Socio-demographic factors associated with patients developing CNSLBP are gender, age, marital/family status (single parent/young children, partner retired or disabled), health condition (mental health conditions musculoskeletal conditions, comorbidities) occupational or educational level, time since last worked, occupational status (no longer employed) and local employment rate (Waddell, 2004).

Plasticity

Plasticity is a dynamic physiological property of all the soft tissue systems to adapt their structural organisation and biochemical, physiological and morphological characteristics temporarily or permanently due to new emerging situations as a result of inherent and environmental situations (which can be internal or external) as well as due to other factors (e.g. injuries) affecting the systems. Plasticity is a constant dynamic adaption in all the systems of the ISMS and enables the body (soft tissues) to adapt to injury and psycho-social and environmental demands (Dorland‘s Illustrated Medical Dictionary, 32nd edition, 2012). In CNSLBP plasticity occurs in muscular, connective tissue, peripheral, central and autonomic neural tissue due to the tissues‘ ability to adapt to the stimuli they are subjected to. It can also influence behaviour based on beliefs and fear avoidance. The process of plasticity is the basis for the adaptation of soft tissues and neural tissue to adapt to internal or external stressors and is proposed by the researcher as an important process in the development of ISMS dysfunction and as such the clinical picture of CNSLBP.

The paradigm of this study

Manual therapy is a clinical area of specialisation in physiotherapy where an aspect of the field of knowledge falls within the empirico-analytical paradigm (biomedical evidence-based knowledge and management of patient problems). Simultaneously due to the fact that manual therapy also requires an interaction between the manual therapist and patient, the patient‘s perspective of his/her problem should also be interpreted and understood to formulate the problem holistically. The manual therapist‘s critical reflection on the patient‘s perspective (illness experience, story, context and culture) and post treatment feedback as well as the patient‘s clinical presentation (biomedical problem) and process of clinical reasoning to manage the patient‘s problem is known as dialectical reasoning (Figure 2.2, Section 2.3.1.2) and is typical of the reasoning process used by clinical experts to generate knowledge (Edwards & Jones, 2007). As a result of the dialectical reasoning process and the fact that the researcher performed metacognitive reflection on the clinical presentation of her patients, her management of the patient‘s heterogenetic CNSLBP problem and the patients‘ responses this thesis also falls within the interpretive paradigm where knowledge is socially constructed. Working in a multidisciplinary team, attending congresses and conferences, presenting post graduate discussions and courses also contribute to the fact that knowledge is socially constructed.

The research approach

The research approach of this study was embedded in the interpretive paradigm as the researcher used a hermeneutic approach to obtain a deeper understanding of the development (causative factors) of CNSLBP and patients‘ responses to manual therapy. The hermeneutic approach to the research was completely integrated and relied on metacognitive reflection on the clinical reasoning process. The result of the hermeneutic approach was a model for the holistic manual therapy approach for managing patients with CNSLBP. The research approach to this study was therefore a hermeneutic metacognitive approach to the development of a clinical management model. Because model development is strongly related to theory development, the study also falls within a grounded theory approach (McEwen & Wills, 2002). A model was chosen as the outcome of the study because in a model the relationships between the concepts that have been identified can be indicated in a way that is inherent to the clinical problem-solving process (McEwen & Wills, 2002). Figure 2.1 presents the research approach in diagram form.

Recommendations for further research

Because the model is dialectic in nature any research that is done to validate the model should take the dialectic nature of the model into consideration. The recommendations for further research therefore include suggestions for research on the ISMS dysfunction as one of the main constructs within the clinical picture of patients with CNSLBP. The main recommendation for further research is that the multidimensional manual therapy model must be empirically validated to be incorporated into the declarative knowledge of Physiotherapy.

Contents :

• List of Tables
• List of Figures
• Abstract
• Background and rationale
• 1.1 Introduction
  • 1.2 The mechanisms in the development of CNSLBP
  • 1.3 Management of patients with CNSLBP
  • 1.3.1 The researcher‘s multidimensional manual therapy approach to the management of patients with CNSLBP
  • 1.4 Problem statement
  • 1.5 Research questions
  • 1.6 Research aims and objectives
  • 1.7 Research approach
  • 1.8 The nature of this study
  • 1.9 Clarification of terminology
  • 1.9.1 Low back pain
  • 1.9.2 Acute specific low back pain
  • 1.9.3 Manual therapy
  • 1.9.4 Multidisciplinary approach to management of CNSLBP
  • 1.9.5 Multidimensional manual therapy for the management of CNSLBP
  • 1.9.6 Chronicity
  • 1.9.7 Dysfunction and disability in patients with CNSLBP
  • 1.9.8 Plasticity
  • 1.9.9 Integrated spinal movement system (ISMS)
  • 1.10 Outline of the study
  • Research methodology
• 2.1 Introduction
  • 2.2 The frame of reference
  • 2.2.1 The paradigm of this study
  • 2.3 The research approach
  • 2.3.1 The hermeneutic process as knowledge-generating process
  • 2.3.2 Model development
  • 2.3.3 The role of literature in the development of a holistic manual therapy model for managing patients with CNSLBP
  • 2.4 Trustworthiness of the conceptualisation of ISMS dysfunction and the development of the multidimensional manual therapy model
  • 2.5 Significance of the study
  • 2.6 Ethical considerations
  • 2.7 Summary of the chapter
  • Mechanisms generating the development of a dysfunctional integrated spinal movement system
  • Introduction
• 3.2 Conceptualisation of the ISMS
  • 3.2.1 The articular components of the ISMS
  • 3.2.2 The muscle system of the ISMS
  • 3.2.3 The neural components of the spine
  • 3.2.4 The connective tissues in the trunk
  • 3.3 Postural control of the ISMS
  • 3.4 Patho-physiological responses underlying the development of ISMS dysfunction
  • 3.4.1 The effect of muscle spasm, overuse and disuse on muscular tissue
  • 3.4.2 The development of trigger points
  • 3.4.3 The process of connective tissue stiffening in patients with CNSLBP
  • 3.4.4 Effects of nervous tension (stress) on the musculature of the body
  • 3.5 Development of integrated spinal movement system (ISMS) dysfunction
  • 3.5.1 Musculoskeletal adaptation to unilateral abnormal spinal loading
  • 3.6 Soft tissue plasticity as an inherent process in the development of ISMS dysfunction
  • 3.6.1 Plasticity and postural control
  • 3.7 Factors that can influence/adapt the typical pattern of ISMS dysfunction
  • 3.7.1 Differences in response of the lower and upper lumbar motion segments
  • 3.7.2 Poor posture and postural control
  • 3.7.3 Disuse and sedentary lifestyle
  • 3.7.4 The process of spinal loading
  • 3.7.5 Cervical and thoracic dysfunction
  • 3.7.6 Association of chronic unilateral low back pain with disruption of tactile input
  • 3.7.7 Neural referred pain through torsioning of the biomechanical ISMS
  • 3.7.8 The effect of stress on spinal dysfunction
  • 3.7.9 The influence of underlying degeneration in the synovial joints of the spine
  • 3.7.10 Previous history of back pain and response to health care management
  • 3.8 Pain processing as integral component driving the development of ISMS dysfunction
  • 3.8.1 The biomechanical origin of pain processing in the development of ISMS dysfunction
  • 3.8.2 The neuromatrix as part of the ISMS dysfunction
  • 3.8.3 Characteristic adaptive behaviour in patients with ISMS dysfunction
  • 3.8.4 Pain modulation
  • 3.9 Conclusion
  • The principles of a multidimensional assessment model for patients with chronic nonspecific low back pain
• 4.1 Introduction
  • 4.2 Typical clinical appearance of a patient with CNSLBP
  • 4.2.1 History taking
  • 4.3 A multidimensional model for the assessment of patients with CNSLBP
  • 4.4 Summary of the chapter and discussion of the holistic integrated model for the assessment of patients with CNSLBP
  • Principles of a multidimensional manual therapy approach to patients with chronic non-specific low back pain
• 5.1 Introduction
  • 5.2 Principles of pain modulation
  • 5.2.1 The therapist as pain-inhibiting agent through a professional therapistpatient relationship
  • 5.2.2 The role of cognitive behavioural therapy in the multidimensional manual therapy of patients with CNSLBP
  • 5.2.3 Pain modulation through manual therapy
  • 5.2.4 The role of pharmacology as part of the holistic approach to manual therapy for patients with CNSLBP
  • 5.2.5 Re-education of postural control
  • 5.3 Principles of multidimensional pain modulation in patients with CNSLBP
  • 5.4 Clinical principles for the treatment of patients with CNSLBP
  • 5.5 Risk factors to take cognisance of during manual therapy
  • 5.6 A multidimensional manual therapy model for management of patients with CNSLBP
  • Conclusion, discussion, limitations and recommendations
• 6.1 Introduction
  • 6.2 Evaluation of the multidimensional manual therapy model for the treatment of patients with CNSLBP
  • 6.2.1 Summary of the multidimensional manual therapy model
  • 6.2.2 Evaluation of the multidimensional manual therapy model against other models used in the management of CNSLBP
  • 6.3 Limitations of this study
  • 6.4 Recommendations
  • 6.4.1 Recommendations for further research
  • 6.5 Summary
• References

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A multidimensional manual therapy model for managing patients with chronic non-specific low back pain